General Summary/Overview

Hiring for all Boston Areas

Full-time and Part-time- potential sign-on bonus

At Mass General Brigham Healthcare at Home, we place great value on being a diverse and inclusive community. Mass General Brigham Healthcare at Home is dedicated to diversity, equity and inclusion as we aim to reflect the diversity of the patients in our local community. We have a dedicated focus on equity. Thus, we believe in equal access to quality care, employment and advancement opportunities encompassing the full spectrum of human diversity: race, gender, sexual orientation, religion, ethnicity, national origin and all the other forms of human presence and expression that make us better able to provide innovative and cutting-edge healthcare and research.

Provide quality, clinical services to patients in various settings in the community. Patient care is delivered within organizational philosophy, policy and standards of community health practice. The admissions process and case management responsibilities are performed in accordance with Mass General Brigham Healthcare at Home policies and standards of practice, utilizing thorough and timely electronic documentation and interdisciplinary communications. Skilled nursing care is provided in the form of assessment, teaching, treatment, documentation, and care coordination demonstrating high quality customer service, and financial awareness.

• Care is provided with a focus on effective utilization and accepted standards of care that result in quality outcomes.
• Initial assessments and visit notes accurately reflect medical necessity, home-bound status, provision of skilled services, vital signs, patient education/comprehension to ensure optimal reimbursement and high-quality patient care in accordance with agency standards and compliance with legal and regulatory requirements.
• Plan of care is developed and periodically updated to address patient-specific needs, preferences, hospital readmission and infection risk, home safety and clinical conditions to ensure optimal patient safety and outcomes. Care plan goals are patient-specific, updated and resolved in a timely manner.
• Patient information and change in status/plan of care is communicated to physician and documented in a timely manner in accordance with agency standards.
• Medications are reconciled accurately at SOC, ROC and Transfer, and changes are integrated into the plan of care. Medications are reviewed at each visit.
• Medical supplies are ordered according to allowable guidelines and wound supplies are managed in consultation with the WOCN.
• Patient schedule is established and submitted timely. Schedules are routinely adjusted and communicated timely with the Clinical Manager and the Scheduler to meet patient and agency needs.
• Point of Care standards are adhered to for submission of data no later than midnight of the day of the visit/admission, including closed and sync'd encounters (exceptions to this standard must be reported to Clinical Manager or designee in the same time period).
• Software is updated by maintaining the latest version of software applications as defined by the IS Department.
• Patient information is prepared and effectively communicated to appropriate departments and team members in accordance with agency standards.
• Referrals are made to other disciplines and to appropriate community resources to meet patient-specific needs and maximize patient safety and outcomes.
• Patients are identified for multi-disciplinary case conferences as needed after Start of Care.
• Patient education is provided in the patient's preferred language and format from time of admission and evaluated on an ongoing basis to meet the needs and abilities of patients and families and is appropriate to the care and treatment provided. Teaching and pt/cg response is clearly documented in the medical record.
• Discharge planning (that includes the primary physician, family, and patient and accesses community resources) is initiated at Start of Care and evaluated on an ongoing basis for optimal patient safety and outcomes and is evident on review of the medical record.
• All patient consent/notification forms are completed as required by Agency policy, law, and regulations, and submitted to the office within 24 hours.
• Patients are informed of and consent to planned visits/visit schedule. Services are delivered in a timely manner and in accordance with patient needs and preferences as evidence by adherence to the plan of care. Patients are contacted if visits will be late or rescheduled and physicians are notified if care is or will be impacted.
• Patients and their families are actively included in the care planning process. Patient notification of and consent to any and all changes is clearly documented in the medical record.
• Quality patient care is consistently demonstrated by adherence to standards of care, appropriate and timely communication, coordination of care, and completion of required clinical documentation.

• Assignments are performed at a complex level, supported by documented competency, including but not limited to high tech visits, end of life care, complex wounds, etc.
• Staff meetings, competencies, training and educational meetings are attended regularly (suggest a standard such as 80% of the time). 100% attendance at or completion of all mandatory education. Clinical initiatives and special training is supported (e.g. EOL lifeline, etc.).

Education/Degree Requirements

Required: Graduate of an approved School of Nursing

Licensure, Certifications or Registration

Required: Current Massachusetts license as Registered Nurse

Experience

• Minimum of one year of previous nursing experience in acute care or sub-acute care setting required.
• Prior home care experience preferred.
• Travel required within MGB Home Care's geographic area.
• Ability to work with various computer software required and knowledge of hand-held patient care computer devices preferred.
• Strong interpersonal and customer services and ability to work with a diverse population.
• Ability to communicate effectively in writing, verbally and electronically.
• Ability to work as a member of an interdisciplinary team of health care providers.
• Ability to organize and prioritize work and adapt to changing situations.
• Ability to work independently, be self-directed and adapt to unpredictable circumstances.

Skills

Physical Environment

Primarily will work in patients' homes. Potential exposure to blood, blood products, body fluids and chemical hazards. Attend meetings in a variety of external organizations, healthcare facilities, hotels and other venues.

Mass General Brigham Healthcare at Home is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.