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Home is home


The registered nurse plans, organizes, and directs home care services and is experienced in nursing, with an emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.


Patient Care

  • Completes an initial home health assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es).
  • Completes initial, comprehensive, and ongoing assessments of patients and families to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es).
  • Conducts home visits as assigned, assessing the patient’s condition, and progress toward goals, providing patient care, teaching, and other skilled interventions as ordered.
  • Regularly re-evaluates patient nursing needs, as part of the nursing visits.
  • Initiates the plan of care and makes necessary revisions as patient status and needs change in collaboration with the Case Manager
  • Uses health assessment data to determine nursing diagnosis.
  • Develops a care plan in collaboration with the Case Manager, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and family in the planning process.
  • Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.
  • Counsels the patient and family in meeting nursing and related needs.
  • Provides health care instructions to the patient as appropriate per assessment and plan of care.
  • Identifies discharge planning needs during nursing visits. Communicates needs to the team as part of the care plan development; assists in implementing before the discharge of the patient.


  • Prepares home health clinical notes and updates the case manager and primary physician when necessary.
  • Completes, maintains, and submits accurate and relevant hospice clinical notes regarding patient’s condition and care given. Records pain/symptoms management changes /outcomes as appropriate
  • Prepares clinical notes and updates the primary physician and/or Medical Director when necessary
  • Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
  • Teaches the patient and family/ caregiver self-care techniques as appropriate. Provides medication, diet, and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the hospice interdisciplinary group or home health interdisciplinary team.
  • Communicates with community health-related persons to coordinate the care plan
  • Attends home health case conferences and/or interdisciplinary group meetings as requested.

Additional Duties

  • Participates in on-call duties as defined by the on-call policy
  • Ensures that arrangements for equipment and other necessary items and services are available
  • Instructs supervises and evaluates home health aide care provided every two (2) weeks
  • Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes
  • Fulfills the obligation of requested and/or accepted case assignments
  • Actively participates in quality assessment performance improvement teams and activities.


  • Registered nurse with current licensure to practice professional nursing in the state
  • Graduate of the National League for the Nursing accredited school of nursing
  • Maintains a current CPR certification
  • Current valid driver’s license
  • Minimum of two years experience, at least one of which is in the area of public health, and home care is preferred
  • Self directed and able to work with minimal supervision
  • Demonstrates excellent observation, problem-solving, verbal and written communication skills; nursing skills per competency checklist
  • Shows ability to organize and prioritize workload independently
  • Management experience is not required. Responsible for supervising home health aides
  • Prolonged or considerable walking or standing. Able to lift, position, or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling, or crouching. Visual acuity and hearing to perform required nursing skills.