Under the direction of a Nurse Manager, the PACE Community Health Nurse (PCHN) provides skilled care and routine clinical nursing assessment visits to PACE members and families utilizing all elements of the nursing process and in compliance with applicable laws, regulations and agency policies. The PACE CHN primarily provides nursing visits in the member’s home in the community but can routinely visit members in the PACE center, hospitals, nursing homes, and other alternate setting as deemed necessary for care coordination consistent with the PACE model of care. The PACE CHN is a core interdisciplinary team (IDT) member who assigned to a PACE member in compliance with CMS PACE regulatory requirement.
- Carries out the agency’s mission, philosophy, goals and objectives within guidelines of Agency policy and position function.
- Interprets and implements the Agency’s philosophy to staff and members of the community.
- Assumes responsibility for assignments given, seeks supervision appropriately, and is accountable for his/her actions by performing within the limits of his/her education and experience.
- Knows and conforms to the law governing the practice of professional nursing and provides professional nursing care using all elements of the nursing process.
- Assesses and evaluates the health care needs of patients and families with consideration regarding physiological, psychological, social and environmental factors.
- Identifies complete, accurate and logical Uniform Assessment System (UAS) for NY and appropriate sequencing of diagnoses in collaboration with the PCP to maintain compliance with state and federal regulations.
- Participates in mandatory PACE comprehensive care planning meetings routinely as required by PACE regulations. Collaborates with all members of the IDT in developing a comprehensive care plan based on member-specific needs, physician orders, UAS-NY CAPS, other IDT assessments, members’ specific parameters and identified goals that are respectful of member, family, community and agency resources.
- Implements the nursing care plan and revises it whenever necessary by regularly assessing, observing, and evaluating the patient’s condition, needs and response to care and makes appropriate nursing judgments and decisions for care plan revision.
- Initiates and applies appropriate preventative, therapeutic and rehabilitative nursing procedures and techniques.
- Administers medications and treatments as prescribed by the PCP. Ability to independently perform skilled nursing procedures and techniques based on the changing nursing needs that the member requires.
- Teaches the patient and family/caregivers self-techniques whenever appropriate and provides instruction regarding medication, diet, safety and treatment modalities in accordance with the plan of care.
- Recognizes and utilizes additional opportunities for health counseling/education with patients, families and other caregivers and provides them with information that will facilitate decisions regarding the promotion, maintenance and restoration of health.
- Delegates responsibility appropriately, and supervises ancillary personnel in a manner that will assure quality care and compliance with the care plan.
- Evaluates for and promotes a safe environment for the patient and complies with National Patient Safety Goals.
- Completes, maintains and submits all required documentation that is timely (in compliance with agency policy) accurate, and relevant.
- Meet all requirements for UAS-NY assessor function: timely completion within regulatory standards, follow-up assessments, and significant change assessments as needed.
- Reviews and confirms eligibility of member in the PACE program based on Nursing Facility Level of Care (NFLOC) score obtained from the UAS-NY assessment. Confirms eligibility of members with the members of the IDT.
- Performs care coordination as part of their nursing visits to PACE members across all settings of care. Collaborative care coordination to include internal (e.g., other IDT members) and/or external health care professional (e.g., MD specialists, SNF staff, hospital staff) in a manner that assures care plan coordination as well as continuity of care.
- Degree from an NLN accredited school of nursing required, BSN preferred
- A current New York State License to practice as a Registered Nurse.
- Experience: Minimum of one (1) year general clinical nursing experience in a certified home health agency (CHHA), acute care, medical surgical, and/or critical care experience required. Clinical nursing experience must be within one (1) year from date of hire or transfer required.
- Possess and maintain good physical stamina and mental health, including satisfactory health clearance as required by NYS regulations and Agency policy.
- Current Driver’s License, required insurance and car available for work as required.
Knowledge, Skills and Abilities
- Computer/laptop proficiency required
- Good organizational, observation, communication and judgment skills.
- Is self-directed with ability to work with supervision.
- Is flexible and cooperative in fulfilling role obligations.
- Works outside in varied weather conditions in all areas of the community, using private or public means of transportation.
- Walks to and from patients’ homes.
- Potential exposure to health hazards.
- Works inside in well lighted, heated or air conditioned office and in varied conditions in patients’ homes.