Home Based Nurse (PACE)

Description

Position Title:                       Home-Based Registered Nurse
Department:                          PACE
Supervisor:                           Nurse Manager
Status/Hours Per Week:      Non-Exempt / 40 hours

Primary Function:

The Home-Based Nurse provides initial and semi-annual nursing assessments for home-based participants; develops and implements nursing plan of care: provides medication management, daily nursing treatments, episodic assessments and nursing interventions at the home; collaborates with Primary Care to provide complete nursing services in a safe, secure, accessible environment with skill, dignity and respect; and completes scheduled/episodic nursing visits for Upham’s PACE participants.

Duties & Responsibilities:

    •    Complete initial and subsequent semi-annual nursing assessments.
•    Implement physician’s orders, and document in medical record.
•    Develop and implement a nursing plan of care for each participant on case load. 
•    Take responsibility for developing and implementing a medication management plan for each participant, i.e. implement physician’s orders, order medications directly from pharmacy, document in medical record, assure administration of medication, provide education and training to participants and/or caregivers when needed to enhance adherence to medication regime.
•    Take responsibility for coordinating medication deliveries on a timely basis.
•    Complete scheduled/episodic skilled nursing visits.
•    Coordinate discharge planning with Center Nurse after ED visits, hospitalizations and nursing home stays. 
•    Provide input in development of participant’s individual care plan.
•    Maintain medical record documentation. 
•    Act as member of inter-disciplinary team – attending morning meetings and weekly clinical meetings. 
•    Participate in rotating on-call and weekend coverage. 
•    Participate in program development and quality improvement activities. 
•    Perform other duties as requested by Nurse Manager. 
 

Qualifications

Minimum Basic Knowledge:

    •    Skilled nursing interventions.
•    Ability to write and implement nursing care plans. 
•    Computer skills for basic health care entry and documentation.
•    Solid verbal communication and writing skills in English.

Experience & Qualifications:

    •    Licensed Registered Nurse in Massachusetts. 
•    Minimum 1 year of experience working with geriatric population. 
•    Must have a car to visit patients’ homes. 
•    Ability to work with multicultural staff, participants, and caregivers.
•    Ability to work as a team member in an inter-disciplinary environment.
•    Bi-lingual language skills in Spanish, Portuguese, and/or Haitian Creole preferred.
•    Discharge planning experience desirable. 

Independent Action:

    •    Coordinate with participants, family members, and Upham’s PACE staff, including HHAs, PCWs, and other vendors for service provision as required.
•    Provide continued education to home health aides, PCWs (Personal Care Workers) as needed.
•    Plan/schedule skilled nursing visits. 

Supervisory Responsibility:
    None

Define Access Level to PHI:    Level 4: Authorized to access full health information. UCC position and job responsibilities involve the provision of patient care and working as a clinical team member. Staff in this category level, although allowed full access, should only access the necessary information for each respective treatment encounter/circumstance.