RN - Home-Based Hospital Care

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

8/13/2026

Entity:

Wisconsin

Job Code:

790038A

Job Title:

RN - Home-Based Hospital Care

FLSA Exemption Status:

Non-Exempt

Management Level:

Individual Contributor

JOB SUMMARY

The RN - Home-Based Hospital Care is an integral part of the Home-Based Hospital Care interdisciplinary care team, providing care to acute patients receiving services in the home setting. The RN - Home-Based Hospital Care provides essential acute virtual clinical care in the home setting and coordinates and directs the patient's care based on individual patient needs. This position is responsible to provide care for the Home-Based Hospital Care patient population requiring the use of advanced assessment, technical, teaching, and decision-making skills. The RN works in collaboration with the interdisciplinary team including the Home-Based Hospital Care provider, Home-Based Hospital Care Nurse Manager, Social Work, and ancillary services to ensure that patients receive exemplary care in their home. The RN is required to work autonomously and apply their critical thinking skills to each patient during the Home-Based Hospital Care episode of care. In addition to clinical skills, the RN must be proficient with home safety assessments and adaptation of patient/caregiver education to each unique patient situation. Collaboration with patients and providers will occur through digital health technology. The RN is responsible for assessing post-acute needs and ensuring that appropriate referrals to other services are made. Interdisciplinary conferencing is a key component of this role's responsibility, and thorough and timely documentation is required.

ESSENTIAL DUTIES

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Performs comprehensive assessments of physical, functional, psychosocial, and cognitive status of the Home-Based Hospital Care patient utilizing interview, observations, and virtual physical exam techniques.

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Assesses the home environment for safety, infection control, and community resource needs.

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Incorporates multidisciplinary data into the nursing assessment of the Home-Based Hospital Care patient.

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Provides ongoing nursing assessment with the patient, caregiver, and home environment to determine physiologic or psychosocial risk. Applies previous nursing experience and base of knowledge and adapts with the patient and caregiver receiving care in a home setting.

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Sets priorities adapting to changing patient and environmental situations. In response to data indicating urgent and/or emergent risk to patient, initiates action to reduce or correct risk.

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Assesses for the presence of advanced directives and facilitates further action in obtaining information about or implementing advanced directives if indicated.

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Plans with the patient, caregiver, and provider for care which is feasible within the physical, financial, and emotional resources of the family.

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Establishes individualized, measurable goals in consultation with the patient, caregiver, and other health care providers.

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Anticipates post-acute needs and seeks a wide range of community resources to facilitate problem solving.

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Maintains technical skills according to required standards, as measured by competency assessments during orientation and annually.

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Implements safe, competent care with Home-Based Hospital Care patients and families within policies, procedures, and standards of care.

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Accurately follows established infection control and safety policies and procedures.

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Directs the use of equipment and supplies in an efficient and cost-effective manner.

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Sets priorities of home and virtual visits, adapting to the changing needs of the patient.

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Utilizes resources to problem solve new or unfamiliar patient situations.

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Works collaboratively with the interdisciplinary team to best meet the needs with the Home-Based Hospital Care patient and family.

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Documents components of the nursing process to reflect a comprehensive and integrated approach to nursing care.

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Recognizes potential problems and sets priorities according to changes in the patient’s condition.

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Informs the provider and other appropriate members of the health care team of changes in the patient’s condition and needs.

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Evaluates patient’s responses to care based on a continuing assessment and analysis of nursing intervention and alternatives for nursing care.

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Facilitates and participates in formal and informal interdisciplinary care conferences to address the needs of regarding complex patients.

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Exhibits sound nursing judgment and decision-making skills in coordinating patient care.

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Identifies and adapts teaching materials for Home-Based Hospital Care patients and caregivers to optimize the learner’s success. Involves the patient and caregiver in identification of individual requirements/perceptions of learning needs.

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Develops, implements, and evaluates individualized teaching programs using teach-back and return demonstration techniques to assess patient/caregiver level of understanding and adjust teaching and plan of care accordingly.

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Maintains an updated clinical record on each patient at all times.

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Participates in the development of program goals and evaluates progress toward goal achievement.

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Participates in committees/meetings as delegated or appointed.

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Involves the patient and caregiver in the plan of care, incorporating their cultural, spiritual, and other belief systems.

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Recognizes the importance of respecting individual patient and caregiver choices regarding care and treatment options.

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Assists leadership in identifying potential clinical practice issues and contributes to the development of specific plans to improve Home-Based Hospital Care patient outcomes

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Acts as a consultant and clinical resource to staff through provision of patient care and coordination of care.

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Serves as a liaison to various campus, community, and national/international healthcare groups.

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Other duties as assigned.

As needed, additional responsibilities reasonably within the scope of duties and physical requirements may be assigned.  ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS AND RESPECT FOR PEOPLE COMMITTMENTS.

X

Clinical

Will provide all patients age and culturally appropriate assessment/screening and interpretation of clinical and laboratory data. Develops and implements age appropriate interventional plans of care including education within the parameters of their position responsibilities and licensure

JOB REQUIREMENTS

Bachelor's Degree

in Nursing (BSN)

Preferred

2 years

relevant acute care or home health nursing experience

Required

Experience in care coordination, triage, or nursing leadership

Preferred

Experience in program development

Preferred

Experience in teaching self-care skills to patients and families

Preferred

Recent, relevant home health experience

Preferred

Experience using EPIC and virtual health platforms

Preferred

Experience with IV therapy and knowledge of venous-access devices and ambulatory pumps

Preferred

Licensed as a Registered Nurse (RN) in the State of WI or holds a license issued by a jurisdiction that has adopted the nurse licensure compact

Required

Current CPR/BLS Certification

Required

Must possess a current, valid driver’s license issued by the individual’s state of residence. Must be of legal driving age to operate a Personal Vehicle for UW Health business purposes. ​

Required

Relevant certification

Preferred

LICENSE, CERTIFICATIONS, AND REGISTRATIONS MUST BE MAINTAINED PER UW HEALTH POLICY. 

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Knowledge regarding the impact of acute and chronic illness on the lives of patients and families in the community

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Ability to function with a high degree of independence, flexibility, and autonomy

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Ability to collaborate with other disciplines to provide care

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Excellent interpersonal and group process skills

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

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Sedentary: Sedentary work involves lifting no more than 10 pounds at a time and occasionally lifting or carrying articles like docket files, ledgers, and small tools. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required occasionally and other sedentary criteria are met.

Up to 10#

Negligible

Negligible

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Light: Light work involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this category when it requires a good deal of walking or standing, or when it involves sitting most of the time with some pushing and pulling of arm or leg controls. To be considered capable of performing a full or wide range of light work, you must have the ability to do substantially all of these activities. If someone can do light work, we determine that they can also do sedentary work, unless there are additional limiting factors such as loss of fine dexterity or inability to sit for long periods of time.

up to 20#

Up to 10# or requires significant walking or standing or requires pushing/pulling of arm/leg controls.

Negligible or constant push/pull of items of negligible weight

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Medium: Medium work involves lifting no more than 50 pounds at a time with frequent lifting or carrying of objects weighing up to 25 pounds. If someone can do medium work, we determine that they can also do sedentary and light work.

20-50#

10-25#

Negligible-10#

☐

Heavy: Heavy work involves lifting no more than 100 pounds at a time with frequent lifting or carrying of objects weighing up to 50 pounds. If someone can do heavy work, we determine that they can also do medium, light, and sedentary work.

50-100#

25-50#

10-20#

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Very Heavy: Very heavy work involves lifting objects weighing more than 100 pounds at a time with frequent lifting or carrying of objects weighing 50 pounds or more. If someone can do very heavy work, we determine that they can also do heavy, medium, light, and sedentary work.

Over 100#

Over 50#

Over 20#

Other - list any other physical requirements or bona fide occupational qualifications not indicated above:

Over 50 lbs.

UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.

THE EMPLOYEE MUST BE ABLE TO COMPLETE ALL PHYSICAL REQUIREMENTS OF THE JOB WITH OR WITHOUT AN APPROVED ACCOMODATION. Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.