Description
Provide skilled, patient-centered nursing care in the home. Assess health needs, develop and implement individualized care plans, monitor patient status, educate patients and caregivers, and coordinate interdisciplinary services. Maintain accurate home health documentation (e.g., OASIS) and ensure compliance with agency, state, and federal regulations. Licensure required.
- • Conduct comprehensive in-home assessments, including physical, psychosocial, and environmental factors.
- • Develop and update individualized home health care plans based on assessments and physician orders.
- • Monitor, record, and report vital signs, symptoms, and condition changes to the provider and care team.
- • Administer prescribed medications and treatments (oral, IM, SQ, IV) and monitor for adverse effects.
- • Perform wound assessment and care, including dressing changes and infection prevention.
- • Manage infusion therapy and central line care per orders and protocols.
- • Educate patients and caregivers on disease management, medications, equipment use, and self-care.
- • Reinforce diet, activity, and therapy plans in collaboration with PT/OT/ST.
- • Coordinate care and communicate with physicians, therapists, social workers, and home health aides.
- • Supervise and evaluate home health aide services and provide direction as needed.
- • Complete timely, accurate documentation in the EMR, including OASIS and visit notes.
- • Assess the home for safety risks and durable medical equipment needs; implement fall prevention measures.
- • Obtain and implement physician orders; arrange labs, diagnostics, or equipment as needed and relay results.
- • Triage patient calls and respond to urgent changes; escalate to the provider or emergency services when indicated.
- • Maintain aseptic technique during in-home procedures; prepare and manage supplies and equipment.
- • Provide infection control education and monitor adherence to standard precautions in the home.
- • Reconcile medications, educate on adherence strategies, and assist with setup per agency policy.
- • Perform point-of-care testing (e.g., glucose, INR) as indicated and report results promptly.
- • Plan and manage visit schedules and caseload to meet plan-of-care frequencies and goals.
- • Participate in interdisciplinary case conferences; evaluate outcomes and modify care plans accordingly.
- • Provide symptom management and support for chronic or end-of-life needs per the plan of care.
- • Refer patients and families to community resources and support services as appropriate.
- • Maintain compliance with agency policies, HIPAA, and state and federal regulations.
- • Travel to patient homes within the assigned area and adhere to safety protocols.
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Tasks & skills:
O*NET occupational data (work activities, skills, knowledge).
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Last reviewed: Jan 2026
