• Communicates significant information regarding patients with other members of a healthcare team and makes necessary recommendations and suggestions to improve the Plan of Care
• Collaborates with the physician and other members of the health team to develop a Plan of Care.
• Assessment of psychological, emotional and/or economical factors affecting patient’s limitations and potential for and/or lack of improvement
• Initial evaluation visit, interim evaluations (as deemed necessary) and discharge evaluation from Social Services are required documentation.
• Assessment of patients needs for long term care including home and family situation, exploring alternatives to in home care arrangement for placement
• Counsel patient, caregiver regarding long term planning and decision making.
• Clinical notes should be written each visit and include progress, or lack of, specific plans, goals, anticipated length of service, referrals made and follow up on referrals
Identify, high risk indicators potentially endangering patients and provide intervention reports situation to Case Managers and proper authorities
Provide brief therapy to facilitate improved coping, adjustment, management, and compliance to medical regimen
Attends staff meetings, participates in in-services, case conferences and Quality Assurance Performance Improvement activity as required
• Prepares clerical and progress notes and submits them in a timely manner to the office.