The PACE Home Care Coordinator RN supervises staff to ensure regulatory compliance and quality while maintaining an optimal level of independence for participants for personal care performed both in the PACE Center and in the participant’s home.  He/she provides technical, organizational and interpersonal skills necessary to efficiently and effectively coordinate the scheduling, communication and documentation of all aspects of the plan of care for personal care and non-skilled home care.  The Home Care Coordinator RN promotes and maintains the health of participants in the community through teaching, counseling and appropriate preventive and restorative services.  He/she is responsible for assessment of non-skilled home health needs and contributing to the plan of care, initial implementation of care plans, and providing personal care, as well as periodic re-evaluation of individual and family personal care needs.  The Home Care Coordinator RN demonstrates the knowledge and skills necessary to assess, plan care for and provide service to frail, elderly participants according to assigned responsibilities and PACE Program standards. is responsible for the general oversight, assessment, planning, and construction of the nursing care delivered to the participant. The home care RN retains responsibility for ensuring that interventions are carried out in accordance with the participant’s care plan and the orders of the participant’s medical providers. May provide care in the PACE Center or in participants’ homes.

Home Care Coordination:

        1.        Manages staff roster and schedules for all home care on a daily, weekly and monthly basis to create the most time-efficient and cost-effective schedule to meet the needs of PACE participants.

        2.        Designs systems for training, orienting, in-servicing, and supervising Center-based and in-home caregiver staff according to program needs and regulatory requirements.

        3.        Supervises Center-based and in-home caregiver staff and directs the provision of quality paraprofessional care by evaluating staff performance and making decisions regarding hiring and retention.. 

        4.        Effectively communicates with participants and their families regarding home care needs, concerns and/or problems with coverage.

        5.        Records, maintains, monitors and verifies accurate home care records, including service documentation, attendance/payroll, in-service, medical records, and billing of contracted services.

        6.        Obtains and tracks equipment, supplies and services, such as durable medical equipment, home-delivered meals, oxygen, medical-response systems, and incontinence supplies as reflected in the care plan.

Assessment and Care Plan:

        1.        Conducts an enrollment assessment to assess home care needs and contributes to the care plan process.

        2.        Participates in on-call coverage to troubleshoot, advise, teach and coordinate the scheduling of participant care.

        3.        Participates in the development and revision of the participant’s plan of care as a member of the Interdisciplinary Team.

        4.        Conducts periodic assessments and evaluations of each enrollee and arranges for non-skilled personal care in the home and/or PACE Center according to the plan of care.

        5.        Counsels and guides participants and families towards self-help in recognition and solution of physical, emotional and environmental health problems.

        6.        Compiles and uses records, reports and statistical information for evaluation and planning of the assigned programs.

        7.        Maintains timely and quality documentation of all services provided.

        8.        May participate in joint team/family meetings to discuss current services, concerns and suggestions for care plan updates and/or revisions.

        9.        Establishes and maintains cooperative working relationships with other program staff, contracted agencies and outside organizations.

      10.      In conjunction with the IDT, communicates effectively with hospital departments to minimize hospital lengths of stay, as appropriate, and allows for a smooth transition for the participant as he/she moves from the hospital to home.

      11.      Participates in quality management program activities, including peer reviews.

 ·       The Home Care RN will be required to provide care to the PACE participant mainly in home, but not limited to the clinic or day center setting.

·       Complete and record vital signs.

·       Observe participants under treatment to identify progress, side-effects of medications and change in condition.

·       Communicates treatments and self-care interventions with participants and their families/caregivers.

·       Administers prescribed medications and injections

·       Provides wound care and assessments.

·       Inserts and monitors urinary catheters per provider orders.

·       Will accurately document within the electronic medical record (EMR) all clinical documentation including but not limited to:

o   Assessments,

o   Progress of care,

o   Vitals, and

o   Communications with participants

·       Educate participants and caregivers on ways to keep out of the hospital, SNF, and/or LTC.

·       Will provide in home assessment for post hospitalization and falls and will document clinical findings in the EMR.

·       Will provide medication education to participants and caregivers per provider orders.

Possibly participate with on-call services.

·       Work collaboratively with the Occupational and Physical Therapist on in-home services needed.

·       Reports directly to PACE Clinical Manager