Responsible for providing home care nursing assessment and interventions along with care planning and coordination of 24 hour care for to PACE participants as part of the PACE interdisciplinary team. Plans and supervises the personal care and ADL assistance tasks of Geriatric caregivers in the home. Makes visits to participant homes, inpatient facilities and other locations as required to assess participant level of care needs, coordinate with participant, family caregivers, other providers and the IDT. Works under general supervision.
Assesses participant s physical and functional needs, along with psychosocial status and needs, home safety, family caregiver burden, etc utilizing professional knowledge, skills of observations and interviewing skills.
Completes assessment documents including DMS-1, UAS, problem lists and interventions and other documentation required for appropriate data collection and analysis as part of a quality assessment and performance improvement program
Develops and implements the home care components and works with other team members to develop a comprehensive Interdisciplinary team plan of care based on the needs of participant and caregivers, and goals mutually acceptable to the participant/family and significant others.
Monitors effectiveness and outcomes regularly and keeps the team informed as to participant progress and level of need. Remains alert to pertinent input from other team members, participants and family members/caregivers. Reviews and revises goals and approaches to member/ family care in coordination with interdisciplinary team members.
Provides initial home care assessments of new members enrolled in the program, and reassesses at appropriate intervals according to PACE standards and the individualized needs of each participant in coordination with the IDT. Completes NYS required assessment tools according to the schedule planned by the IDT
Communicates with primary care providers and center nurses as needed to coordinate medication, ancillary tests and functions such as home blood draws as needed
Directs the provision of personal care, nursing rehabilitation tasks and other work of Home Health Aides and Geriatric Caregivers in the home.
Coordinates the medication delivery and administration processes for participants requiring assistance at home.
Coordinates with the Primary Care team on obtaining of Advance Directives; educates member/ family on their right to develop Advance Directives which may include Health Care Proxy, Living Will, DNR, Durable Power of Attorney and/or Burial Plans.
Educates and assesses the participant /family understanding of nursing needs and their capabilities for self care or family completion of allowable nursing tasks.
Documents changes in the participant s condition and details care provided by completing all required PACE documentation and ensuring compliance to Agency standards and policies.
Travels to patients homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options to deliver direct care to the participant as appropriate within the regulations.
Manages home care nursing planning for a caseload of participants. Maintains productivity sufficient to meet program goals.
Assists the interdisciplinary team members including the physician, as appropriate, in understanding the significant nursing, self care and functional needs related to the participant s health problems.
Utilizes appropriate community resources and serves as a liaison between the program and other community agencies.
Provides nursing services in accordance with NYS Department of Education requirements and nursing scope of practice, agency policies, practices, and procedures.
Formal Education: Associate Degree or Higher
Experience: 1 year
License, Registration, and / or Certification Requirement: Yes
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