Care Coordination

Core Responsibilities of a Skilled Home Health Nurse

Patient Assessments: Monitoring vital signs, evaluating overall health status, and documenting progress. 

Wound Care: Dressing changes, wound cleaning, and monitoring for infection. 

Medication Management: Administering medications, teaching patients how to take them, and monitoring for side effects. 

IV Therapy: Starting and maintaining intravenous lines, administering fluids or medications. 

Chronic Disease Management: Helping manage conditions like diabetes, COPD, heart failure, etc. 

Patient and Family Education: Teaching self-care techniques, medication routines, and disease management strategies. 

Care Coordination: Communicating with doctors, therapists, and other healthcare providers to ensure cohesive care. 

Typical Patients

Post-surgical patients 

Individuals recovering from illness or injury 

People with chronic conditions needing monitoring 

Elderly patients requiring assistance to avoid hospitalization

PT Key Responsibilities

• Patient Evaluation: Assess mobility, balance, strength, coordination, and pain levels.

• Develop Care Plans: Create personalized treatment plans based on physician orders and patient needs.

• Therapeutic Exercises: Guide patients through exercises to improve strength, endurance, and range of motion.

• Mobility Training: Help patients learn or re-learn how to walk, use assistive devices (like canes or walkers), and navigate their homes safely.

• Pain Management: Use techniques such as manual therapy, stretching, or modalities like heat/ice and TENS.

• Patient & Caregiver Education: Teach safe techniques for movement, transfers, and daily activities to prevent falls or injuries.

• Progress Monitoring: Track and report progress, adjust plans as needed, and coordinate with the broader healthcare team.