2022 SCHCHA H.O.M.E. Award Nomination Form

2022 SCHCHA H.O.M.E. Award Nomination Form

Submissions are due by 8/5/2022 at 5pm.
Honoring

Oustanding

Merit

Excellence

THANK YOU for nominating a HERO from your agency! SCHCHA’s Annual HOME Award Ceremony is a special event and nominating someone for these awards is an opportunity to celebrate all the great things they do each and every day.

We are pleased to be presenting the following five awards this year in these categories: (1) Nurse of the Year (2) Family Caregiver of the Year (3) Physician of the Year (4) In-Home Aide of the Year (5) Volunteer of the Year

GUIDELINES:
- Be sure to answer each question for the award for which you are submitting a nomination.
- Do not use the name of the nominee or any identifying information (such as agency name) on your narrative or in your answers.
- The only place the nominee’s name and agency should appear is in the Nominee First and Last Name Fields at the top the category, not in your narrative responses.
- The Association's P.D. (Professional Development) Committee will receive the narrative portion of the nominations only so that the award selection process will remain anonymous.
- The form will not save your work if you do not hit the Submit button, so it may be best to answer the questions on a Word document first, then copy and paste into the form when the nomination is final.
- Contact adrian@ahhcnc.org with questions.
Nurse of the Year

This award is designed to recognize and reward a registered nurse with at least 3 years experience in home care, home health or hospice who has dedicated their career and professional contributions to the field of home health or hospice care and has the heart of a teacher. This category seeks to highlight a commitment, passion and selflessness to delivering quality care, professionalism and patient outcomes.
Nurse of the Year Nominee's Full Name

First Name Last Name
Nominee's Title/Credentials
Nominee's Agency Name
Nominee's Agency Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Number of Years Worked in Home Care and Hospice
Nurse of the Year: To submit a nomination form on an eligible individual, address the following items in the blank space provided. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. The only place the nominee’s name and agency should appear is in the Nominee Profile information above. This process will ensure the committee can review the nominations without access to identifying information of the individual nominated. Please describe your nominee by responding individually to the following items:

What has been a major contribution of this individual to the home health, home care or hospice nursing profession (50 points) How has this person gone above and beyond in their position to help educate others? Provide examples. (25 points) Demonstrate how this person has advocated for patients and the home care and hospice industry at large. (25 points)
Answer the Questions Above in the Space Provided
Family Caregiver of the Year

This award is presented to a non-paid friend or family caregiver who goes above and beyond the call of duty to promote patient/client well-being and enhanced quality of life including but not limited to factors such as comfort, safety and independence.
Caregiver of the Year Nominee's Full Name

First Name Last Name
Nominee's Title/Credentials
Nominee's Agency Name
Nominee's Agency Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Number of Years of Caregiving in Home Care and Hospice
Family Caregiver of the Year: To submit a nomination form on an eligible individual, address the following items in the blank space provided. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. The only place the nominee’s name and agency should appear is in the Nominee Profile information above. This process will ensure the committee can review the nominations without access to identifying information of the individual nominated. Please describe your nominee by responding individually to the following items:

Describe how the caregiver promotes the patient/client’s well-being, quality of life, and maximum independence. (30 points) Describe the caregiver’s ability to learn care instructions and to intervene appropriately. (20 points) Describe the adjustments made in caregiver’s personal life to provide care. (20 points) Other attributes (attitude, flexibility, dependability, willing to advocate) (20 points) This caregiver deserves this distinguished award over all other nominees because . . . Use 100 words or less. (10 points)
Answer the Questions Above in the Space Provided
Physician of the Year

This award is presented annually to a S.C. physician who has demonstrated a philosophical commitment to assisting home health and/or hospice patients who wish to remain at home.
Physician of the Year Nominee's Full Name

First Name Last Name
Nominee's Title/Credentials
Nominee's Agency Name
Nominee's Agency Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Number of Years Worked in Home Care and Hospice
Physician of the Year: To submit a nomination form on an eligible individual, address the following items in the blank space provided. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. The only place the nominee’s name and agency should appear is in the Nominee Profile information above. This process will ensure the committee can review the nominations without access to identifying information of the individual nominated. Please describe your nominee by responding individually to the following items:

Care-planning Process – actively participates in the care planning process, Understands Medicare/Medicaid coverage guidelines; timely paperwork completion/signature in accordance with regulatory requirements; Communicates problems with the plan of care instead of deleting care on orders (30 points) Care management and collaborative team approach – demonstrates excellence in care management to enhance patient care and quality of life. Courteous, respectful, listens and is available to staff during and after hours regarding patient care. (30 points) Outstanding consultative services – available for inservices, willing to share knowledge, discuss information on disease management, protocols, equipment, etc. Available to review policies, procedures on a consultative basis. (20 points) Other attributes – serves above and beyond the call of duty, patient advocate, makes home visits, participates in case conference (20 points)
Answer the Questions Above in the Space Provided
In-Home Aide of the Year

This award is designed to recognize in-home aides in the home health and hospice industry. The nominee must have a minimum of one year experience working in home health and/or hospice.
In-Home Aide of the Year Nominee's Full Name

First Name Last Name
Nominee's Title/Credentials
Nominee's Agency Name
Nominee's Agency Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Number of Years Worked in Home Care and Hospice
In-Home Aide of the Year: To submit a nomination form on an eligible individual, address the following items in the blank space provided. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. The only place the nominee’s name and agency should appear is in the Nominee Profile information above. This process will ensure the committee can review the nominations without access to identifying information of the individual nominated. Please describe your nominee by responding individually to the following items:

Describe the care provided by this individual and how he or she serves as an advocate for patients. (30 points) Describe how this individual supports other members of the interdisciplinary team. (25 points) Describe this individual’s work habit and how he/she demonstrates excellence. (15 points) Describe efforts undertaken by this individual to enhance their professional growth. (10 points) This individual deserves this distinguished award over all other nominees because . . . Use 100 words or less. (20 points)
Answer the Questions Above in the Space Provided
Volunteer of the Year

This award is designed to recognize Volunteers in Home Care/Hospice. The nominee must have a minimum of one (1) year experience volunteering in hospice.
Volunteer of the Year Nominee's Full Name

First Name Last Name
Nominee's Title/Credentials
Nominee's Agency Name
Nominee's Agency Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Number of Years Worked in Home Care and Hospice
Volunteer of the Year: To submit a nomination form on an eligible individual, address the following items in the blank space provided. Do not use the name of the nominee or any identifying information (such as agency name) in your answers. The only place the nominee’s name and agency should appear is in the Nominee Profile information above. This process will ensure the committee can review the nominations without access to identifying information of the individual nominated. Please describe your nominee by responding individually to the following items:

Recount examples of this volunteer’s actions that demonstrate their caring nature (350 words or less). (40 points) When others comment on this volunteer, what are the most common descriptors used? (20 points) 3. What do patients/clients and families and staff most value about this volunteer’s contributions to your agency ( ~100words) (20 points) Describe the value of the volunteer’s caring spirit to your agency (100 words or less). (20 points)
Answer the Questions Above in the Space Provided

Information of the Person Submitting the Nomination
Nominator's Full Name *

First Name Last Name
Nominator 2 if applicable

First Name Last Name
Nominator's Title and Credentials *
Nominator's Agency Name *
Nominator's Agency Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Nominator's Phone Number *

Area Code Phone Number
Nominator's E-mail *
Should be Empty:

2022 SCHCHA H.O.M.E. Award Nomination Form

Nurse of the Year

Family Caregiver of the Year

Physician of the Year

In-Home Aide of the Year

Volunteer of the Year

Information of the Person Submitting the Nomination