Performing physical exams and patient observations.Recording patients' medical histories and symptoms.Creating patient care plans and contributing to existing ones.Ordering, administering, and analyzing diagnostic tests.Monitoring and operating medical equipment.Diagnosing health issues.Administering medicine and other treatments.Detecting changes in patients' health and modifying treatment plans, as needed.Consulting with healthcare professionals and families.Training patients and their families to manage and prevent illness and injury.

Performing physical exams and patient observations.Recording patients' medical histories and symptoms.Creating patient care plans and contributing to existing ones.Ordering, administering, and analyzing diagnostic tests.Monitoring and operating medical equipment.Diagnosing health issues.Administering medicine and other treatments.Detecting changes in patients' health and modifying treatment plans, as needed.Consulting with healthcare professionals and families.Training patients and their families to manage and prevent illness and injury.

Interprets and implements the Agency's philosophy to staff and members of the community.Works with the Hospital team (physician, social worker, discharge planner, skilled nursing facility staff and or nurse) to assess patient’s home-care needs, safety 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.Screen/review the referral for appropriate level of care and if meets criteria for services being orderedExplains home health agency services and policies to patient and family.Investigates and verifies insurance to ensure coverage criteria is met, notifies patient/family of any financial co-pays and requirements required to obtain home care services. (i.e., CMS face-to-face requirements)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.Arranges for special medical supplies and/or equipment needed, in coordination with discharge planner or social worker.Assures that the home health agency is ready to meet the patient’s needs at discharge by communicating the information to the home health agency regarding the patient and by arranging for the Agency's staff to learn unfamiliar procedures related to the patient’sProvides feedback to hospital health team and/or skilled nursing facility after the patient’s discharge.

-Performing intake assessments. -Evaluating and establishing a plan of care for patients referred for home health services. -Facilitating admission of referrals upon discharge from New York Presbyterian Brooklyn Methodist Hospital to a home care program that meets the needs of the patient and family members. -Developing and maintaining positive relationships with physicians, social workers, case managers and discharge planners within the medical center. -Identifying and directing care to in-network providers of post-acute or post sub-acute services to meet the patient's needs.-Assisting patients and and family in dealing with psycho-social issues affecting treatment plan,as a part of case management process.-Assisting patients and family in anticipating and overcoming obstacles to a safe discharge into the community.-Performing Chart Review.- Coordinating with the discharge planning team to and family members to prepare for transition.-Ordering DME, Infusion, home health to support the patient' s needs in the community.-Reviewing and recommending appropriate transportation for orthopedic patients and those with chronic illnesses.

Assess, plan, implement and evaluate  nursing care at an advanced level, in an unpredictable environment;Manage clinical caseload;Undertake research and audit Delegate care and responsibilities to other team members and supervise appropriately;Develop a culture of learning by mentoring, supervising and teaching registered and unregistered staff.Perform supervisory and managerial functions; including but not limited to employee screening, training, supervising, administration of performance evaluations, disciplining and, as appropriate, terminating.Support others in their development of autonomous practice.Perform UAS assessment and review.Perform enrollment and start of care.Elaborate, review, and revise plan of care.

Perform daily physical assessment and medication administration in office. Perform patient's Initial Assessment and reassessment at home. Complete online assessment through Uniform Assessment System (UAS) through the Department of health's health commerce system.Identify patient care requirements by establishing personal rapport with patients and other persons in a position to understand care requirements.Establish a compassionate environment by providing emotional, psychological, and spiritual support to patients, and families.Promote patient's independence by establishing patient care goals; teaching patient, to understand condition, medications, and self-care skills.Assure quality of care by adhering to therapeutic standards.Measure health outcomes against patient care goals and standards. Make or recommend necessary adjustments. Follow agency's philosophies and standards of care set by state board of nursing, state nurse practice act, and other governing agency regulations.Resolve patient problems and needs by utilizing multidisciplinary team strategies.Maintain safe and clean working environment.Maintain nursing supplies inventory by checking stock to determine inventory level; anticipating needed supplies.Supervise Personal Care Worker in the delivery of care to patients.

Review Health Records.Connect with parents and teachers regarding findings.Provide support and guidance on family issues.Train staff on health issues and reinforce safety.Assess children for developmental milestones.