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This site contains information on a nursing program that is designed to help individuals, their caregivers, foster home providers and case managers develop the supports needed to help a Medicaid eligible person with chronic health care needs live in their own home or foster home.

Referrals and authorization for the service are made by each persons case manager. These ongoing services can be provided in conjunction with short-term home health services which are a different type of community nursing authorized by a physician and funded through the persons medical insurance plan.

The service can only be provided by either self-employed RNs or RNs employed by In-Home/Home Health agencies. Both types of providers must have a contract with the Oregon Department of Human Services Seniors and be enrolled as a Medicaid Provider. Registered Nurses (RN) in the LTC Community Nursing program provide:
  • A nursing assessment, medication review and service plan for the person

  • Health education for the person, caregivers, foster home providers and/or family members

  • Teaching for the individual who self directs their care or family members on how to perform tasks of nursing

  • RN delegation of nursing care tasks provided by a non-family or paid care provider

  • Technical assistance and progress summaries to the case manager regarding the person's healthcare needs

  • Care coordination with the persons medical and ancillary health providers