Overview
The Nurse Liaison facilitates the transfer of patients from a hospital or skilled nursing facility to the care of the home health agency in compliance with applicable laws, regulations and Agency policies.
Responsibilities
Works with the Hospital team (social worker, discharge planner, skilled nursing facility staff and or nurse) to assess patient's home-care needs and establish a discharge plan.
Interviews patients and family to assess the patient's understanding of illness and determine patient's home environment and support system.
Evaluates patient's level of comprehension if procedures and/or treatment need to be performed, e.g. insulin injections, dressings, ostomy care.
Discusses with medical staff, treatment in hospital, and the patient's response to illness.
Explains home health agency services and policies to patient and family.
Assesses third-party coverage and determines if coverage is sufficient to cover the patient's needs at home.
Discusses with patient and family other community resources, where appropriate.
Makes referrals to other agencies if additional services are needed, such as meals from a nutrition center, volunteer services, etc.
Qualifications
Bachelor of Science degree in Nursing from an approved school is preferred.
Will consider social work candidates LMSW/LCSW
Current New York State license as a Registered Professional Nurse; if considering social work candidates, they must be licensed.
Ability to plan, problem solve, set priorities and take appropriate action.
Knowledge of Medicare and Medicaid regulations and commercial insurance.
Possess good interpersonal, leadership and documentation skills.