06/19/2020
- Conduct face to face assessments of clients needs
- Make visits for initial nursing assessments (referrals)
- Identifying gaps or barriers in care plans or service plans
- Patient education
- Communicate monthly with clients and caregivers to meet state regulated guidelines
- Coordinating services for clients
- Make referrals to outside resources
-Coordinate services as needed ( home health, DME’s)
- Conducting post hospitalization assessment and adjustments to the clients service plans