Provide in-home direct patient care according to the provider’s prescribed plan of care (and nursing scope of practice) while closely monitoring progress/recovery. Complete skilled assessments and provide exceptional patient-centered care in the home. Ensure an accurate evaluation and implement a comprehensive care plan that addresses patient needs. Communicate patient conditions and collaborate with appropriate providers to deliver care when patient needs evolve. Complete all clinical documentation in accordance with agency protocol and Medicare/Federal guidelines. Provide education to patients and family members involved in patient’s care. Work to decrease readmissions by promoting preventative care and ensuring continuity of care.