Community Health Nurse

Summary: 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 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.