Job Summary
The CAPABLE Registered Nurse provides in-home nursing services to participants enrolled in the CAPABLE (Community Aging in Place – Advancing Better Living for Elders) program. This person-directed, evidence-based initiative aims to help older adults live safely and independently at home. Under the supervision of the CAPABLE Project Coordinator and in collaboration with the Occupational Therapist and handy worker, the RN supports each participant in identifying health-related goals, addressing barriers to function, and implementing interventions that improve quality of life and reduce hospitalization risk. The employee may also provide in-home RN services for the certified home health care agency, independent of the CAPABLE project.
Job Duties and Responsibilities
The CAPABLE RN is supervised by the Project Coordinator, with a dotted line to the Director of Patient Services (DPS). The job duties and responsibilities are to be performed while observing the following standards: job standard (knowledge, ability, skills) technical skill, quality, quantity, judgement/problem solving, decision making, and initiative.
The responsibilities include, but are not limited to the following:
- Complete CAPABLE training as required by the CAPABLE National Center.
- Conduct in-home assessments focused on health, function, pain, medication, and wellness.
- Collaborate with each participant to identify 3–5 functional goals and develop a care plan.
- Provide health coaching and education in areas such as medication management, fall prevention, chronic disease self-management, and pain reduction.
- Provide education to patient/family/caregiver concerning knowledge deficits or needs regarding the patient’s condition.
- Coordinate with the Occupational Therapist and handy workers to ensure alignment of goals and interventions.
- Submit documentation and participant evaluations in a timely and accurate manner using the home care data system.
- Maintain clinical records in compliance with CAPABLE and OALTC standards.
- Communicate changes in participant status to the CAPABLE Project Coordinator, Director of Patient Services and Primary Care Provider, if necessary.
- Participate in interdisciplinary case reviews and team meetings.
- Receive assignments from a supervisor and complete all assigned visits.
- Promote program awareness and assist with community outreach, if applicable.
- Perform other related duties and responsibilities as required by their manager.
Working Environment
The CAPABLE RN provides services in participants’ homes and is subject to environmental conditions specific to each setting. The schedule is determined by participant need and program capacity. Some flexibility is required.
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