GENERAL DESCRIPTION:
Under the supervision of the Home Health Nursing Supervisor, the Home Health (HH) Registered Nurse (RN) on-call is responsible for providing on-call nursing coverage during assigned shifts to ensure continuity of care for all Bienvivir participants. The RN will answer calls via telephone and provide clinical triage by responding to participants, family, on-call MD/NP and caregiver calls, and determine the need for Skilled Nursing (SN) visits. The RN conducts scheduled and as-needed SN visits to complete triage assessments, manage symptoms, and address changes in participant condition. The RN provides direct nursing care with an emphasis on effective communication, symptom and disease management, participant and caregiver education, prevention and maintenance interventions, accurate documentation and regulatory compliance, in accordance with Texas Health and Human Services Commission (HHSC) requirements. 

CORE RESPONSIBILITIES:

Communication
1. Be available via telephone to receive and prioritize calls from BSHS telephone answering system and to follow up with participants’ medical needs and concerns. 
2. Monitor and retrieve voicemail messages during assigned on-call hours. Return calls in a timely and professional manner. Coordinate with nurse triage line, providers, or emergency services as needed. Triage participant concerns based on clinical urgency; providing clinical guidance based on scope of practice.
3. Manages after-hours communication related to participant emergency room visits, hospital admissions, and discharges. Responsibilities include notifying providers and the interdisciplinary team, coordinating and reviewing discharge orders, communicating care needs to facilities or caregivers.
4. Work in coordination with other after-hours on-call staff via phone to address participant medical needs and arranging urgent medications, DME, or services.
5. Communicate effectively with participants, caregivers, and designated representatives to coordinate care and respond to clinical concerns and phone calls promptly.
6. Maintains communication regarding participant’s care with the Provider, HH Nursing Supervisor, and family, as appropriate.
7. Provides a comprehensive end-of-shift email report to support continuity of care, detailing all interventions and resolutions rendered.

Direct Participant Care
1. Performs Skilled Nursing visits in participants’ private residences, assisted living facilities, and other approved locations for Bienvivir participants.
2. Provides nursing interventions according to the participants plan of care
3. Administers medications and treatments per provider orders.
4. Facilitates transitions of care and supports continuity across settings, including hospital, skilled nursing facility, and home transitions.
5. Observes participants for changes in condition and promptly reports findings to the provider and/or designee.

Nursing Assessments
1. Completes Start-of-Care, routine, and as-needed nursing assessments, including evaluation of medication compliance, symptom burden, functional status, changes in condition and death assessments within 24 hours of participant encounter.
2. Completes reassessments promptly at the request of the participant, designated representative or on-call MD/NP, with urgency determined by clinical severity, during shift.
3. Documents all assessment findings accurately and timely in the medical record within 24 hours of participant encounter.
4. Performs death assessment and pronouncement if appropriate, following organization policies and Texas Health and Safety Code. 

Symptom and Disease Management (Comfort Care)
1. Implements evidence-based interventions for participants with advanced illness and chronic disease.
2. Monitors disease progression and symptom trends through ongoing assessments and telephone follow-ups with participants and/or caregivers, adjusting care proactively as needed.
3. Supports chronic disease management within a comfort-focused plan of care, prioritizing symptom relief and minimizing burdensome interventions.
4. Collaborates closely with Comfort Care providers to recommend medication adjustments, alternative therapies, and supportive measures consistent with participant goals.
5. Ensure all assessments, interventions, communications, and participant responses are documented accurately and timely in the medical record.

Health Education and Support (Comfort Care)
1. Provides ongoing education to participants and caregivers regarding disease processes, anticipated progression, and comfort-focused care expectations.
2. Educates participants and caregivers on medication purpose, administration, potential side effects, and end-of-life comfort medications.
3. Instructs on symptom monitoring, comfort measures, safety practices, and effective self-management strategies.
4. Reinforces Comfort Care Program education in a culturally sensitive, participant-centered manner.
5. Provides emotional support to participants and caregivers, addressing coping, comfort, and care-related concerns.
6. Identifies risk factors and initiates preventive interventions aligned with comfort care principles.

Prevention and Maintenance
1. Implement strategies to prevent avoidable hospitalizations and emergency department visits.
2. Prevents complications such as skin breakdown, falls, medication errors, and unmanaged symptoms.
3. Monitors and promotes skin integrity, nutrition, hydration, and mobility within participant tolerance and goals of care.

Documentation and Compliance

1. Documents all assessments, interventions, education, communications, and participant responses accurately within 24 hours of encounter.
2. Ensures documentation reflects skilled nursing services, medical necessity, and alignment with the established plan of care.
3. Maintains compliance with HHSC requirements and nursing practice standards.

Team Collaboration

1. Ensures coordination of 24-hour service delivery.
2. Maintains ongoing communication with the Home Health Nursing Supervisor and/or Administrator regarding participant status, care delivery, and problem resolution.
3. Escalates clinical concerns, changes in condition, and safety issues promptly.

Other Responsibilities

1. Participates in holiday and assigned on-call rotations, providing telephone triage, addressing family and caregiver concerns, and conducting home visits as clinically indicated.
2. Attend Home Health meetings, in-person and online in-services, and mandatory training.
3. Audits Skilled Nursing and Comfort Care visit documentation on a weekly basis and maintains the QA spreadsheet to ensure compliance with Texas Health and Human Services Commission (HHSC) requirements.
4. Notifies staff of audit findings and provides guidance on required documentation corrections, as indicated.
5. Participate in competency assessments and performance monitoring.
6. Participate in professional organizations and continuing education activities, when appropriate.
7. Performs other duties as assigned by the Home Health Nursing Supervisor or HH Administrator.
8. Protects participant confidentiality in accordance with HIPAA.

QUALIFICATIONS / REQUIREMENTS: 
1. A graduate from an approved professional accredited school of nursing, licensed to practice in the State of Texas.
2. Currently licensed (in good standing) through the State Board of Texas as a registered nurse. 
3. Have at least one year experience as an RN obtained within the last 36 months. 
4. Experience in triaging the frail elderly in either a hospital, clinic, or home health setting. 
5. Over 2 years’ experience in Home Health and/ or PACE setting preferred.
6. Current CPR card.
7. Current TB test and/or chest X-ray.
8. Must have reliable transportation, valid driver license and current insurance.

KNOWLEDGE, SKILLS, AND ABILITIES: 
1. Must have strong assessment skills and be able to work in a practice environment independently while making sound clinical decisions.
2. Must have strong and effective telephone and interpersonal communication skills. 
3. Bilingual (Spanish/English).