Location: West Volusia, New Smyrna, Edgewater territories.
Hours - Full Time Days
The Home Health Occupational Therapy (OT) Care Manager is a professional therapist who coordinates and directs the home care patient’s services based on individual patient needs. The OT Care Manager is responsible for independent management of the Home Health patient population requiring the use of advanced assessment, teaching and decision-making skills. The OT is responsible for ensuring that appropriate referrals to other services are made, interdisciplinary conferencing takes place regularly, and appropriate documentation is completed. Relevant knowledge and experience is consistently applied to new patient populations. The OT Care Manager cares for a caseload of home health patients requiring occupational therapy as the primary service by evaluating the patient for appropriateness of home health and developing the home care plan in conjunction with the physician. S/he educates patients, families, caregivers and community providers to safely perform care. S/he provides follow up by evaluating effectiveness of the home care plan, and monitoring patient/family’s response to the plan to achieve patient/family goals and top decile outcomes. The OT Care Manager also identifies performance improvement and home health standard of care initiatives and assists to design or implement programs to address needed changes.
Prinical Duties and Responsibilities
• Coordinates and directs the care of a caseload of home patients requiring occupational therapy as the primary skill. Provides comprehensive assessment, planning, implementation and evaluation for that caseload as the primary Care Manager. • Performs an evaluation, assessing function using a method which objectively measures activities of daily living such as, but not limited to, eating, swallowing, bathing, dressing, toileting, walking, climbing stairs, using assistive devices and mental and cognitive factors, documenting the measurement results in the clinical record. Sets priorities of home care caseload adapting to the changing needs of the home care patients and families. Optimizes schedule daily to support productivity, efficiency and maintain best practice visit utilization. • Assesses physical, functional, psychosocial, social, spiritual, educational, developmental, cultural, cognitive status and discharge planning needs of the home care patient utilizing interview observations and physical exam techniques. Assesses the home environment for safety, infection control, and community resource needs. Reviews patient history and physical, diagnostics and laboratory data. Reviews available information obtained by other team members. Reports abnormal items and results to the physician as appropriate and reviews with patient family. Accurately and timely documents these assessments. • Utilizing assessment data, formulates a patient specific plan of care along with the patient, family and physician which is feasible within the physical, financial and emotional resources of the family. Establishes individualized, realistic, measurable patient centered goals in consultation with the patient, family and other health care providers including goals to improve or stabilize patient’s medical condition, functional abilities and promote independence. Considers the physical, cultural, psychosocial, spiritual, age specific and educational needs of the patient when developing the plan of care. • Implements the plan of care through direct patient care, coordination, delegation and supervision of the activities of the health care team. Provides care based on physician’s orders, in compliance with policies and procedures, standards of care, and regulatory requirements. Selects, applies or modifies skilled intervention consistent with training and scope of practice using various procedures and techniques to achieve the best outcome possible for the patient. (Ex: therapeutic exercise/activity, neuromuscular re-education, fine motor training, perceptual retraining, cognitive retraining, sensorimotor activities, orthosis fabrication, etc.) Assesses patient response to interventions and performs reassessments as required. • Delegates appropriately and provides supervision in the provision of care to patients by other licensed staff and other personnel. Promotes continuity of care by accurately and completely communicating to other caregivers the status of patient for whom care is provided. Provides skilled care, preventative rehabilitative procedures, and prescribed treatments with a variety of patient populations within various potentially complex home situations. Periodically reassess the patient every 30 days: provide the ordered therapy service, functionally reassess the patient and compare the resultant measurement to prior assessment measurements. Document the measurements in the clinical record along with the therapist’s determination of the effectiveness or therapy or lack thereof. • Uses motivational interviewing/health coaching techniques to engage key stakeholders in the management of care. Evaluates patient’s and family’s responses to care and teaching and effectiveness of teaching based on a continuing assessment and analysis of nursing intervention and alternatives for nursing care. Ensures that the home care patient and family demonstrate the knowledge and abilities regarding home care rights and responsibilities, diagnosis, health care status, treatment, skills, medication regime, advance directives, and adaptive behaviors gained as a result of teaching interventions. Initiates change in the care plan as needed. • Informs the physician, clinical manager, and other appropriate members of the health care team of changes in the patient’s condition and needs. Facilitates and coordinates interdisciplinary care conferences with groups of complex patients. • Maintains an updated clinical record on each patient at all times, meeting required deadlines for documentation of certification, re-certification, aide supervision reports, aide care plan updates, routine recording of case coordination, care plan updates, addressing progress toward goals, and verbal orders. • Provides care based on the best evidence available and may participate in research activities within clinical practice. Interacts and participates in the education, role development, and orientation of agency personnel promoting and supporting growth of other through precepting and mentoring as needed. Takes ownership to optimize agency performance through active involvement in quality improvement activities.
REQUIRED: • Minimum of one-year relevant clinical occupational therapy experience • Master’s degree in Occupational Therapy • Current Occupational Therapy License in State of Practice • Valid Driver’s License and current car insurance • CPR certified
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.