The self-directed public health nurse provides home care services to Kaiser Permanente patients in community based and facility settings. This position may provide nursing services to patients in the home health, hospice, home infusion, palliative care, or other programs under the direction of the patients physician(s) to provide quality health care outcomes and facilitate the achievement of maximum independence of the patient utilizing health care resources within Kaiser Permanente and the community.

• Provides nursing services to patients consistent with agency policy, state practice acts, and applicable state and federal regulations as directed by the patients physician. Manages the care of patients from admission to discharge, coordinating the multidisciplinary plan of care: including appropriate referrals to other disciplines; community resources; supervision of the home health aid plan of care; coordination of the discharge plan and documentation to reflect all activities provided in program appropriate care settings.
• Assesses the learning needs of the patient/caregiver to develop the plan of care that meets patient and family needs and goals including the provision of effective teaching, supervision and delegation of care to achieve desired health care outcomes and timely discharge consistent with quality care.
• Partners with agency management in the development and review of programs within Continuing Care Services. Facilitates the initiation of cost effective home care and provides consultation to clinicians regarding appropriate care setting alternatives.
• Assures professional competency through maintaining state-of-the-art skills and knowledge consistent with Medicare and JCAHO regulations, applicable nurse practice acts and agency policies.
• Participates in hospice, home infusion, home health and palliative care call duty consistent with agency policy.
• Participates in department quality management/improvement activities; including but not limited to clinical record review, occurrence reporting, focused studies, process and outcome measurement, peer review, continuous quality improvement projects, partners in defining and achieving agency productivity standards.
• Performs other duties as requested.