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PRIMARY RELATIONSHIPS: Medical Director, Executive Director, Center Manager, Clinical Services Manager Health Care Coordinator, In-Home Services Supervisor, co-workers, participants, family members and public.
OBJECTIVE: Under the supervision of the Medical Director provides primary care to participants. Performs physical assessments of new PACE Enrollees, semi-annual reassessments of participants and develops and implements appropriate plans of care to Senior CommUnity Care program participants. Evaluates participant physical complaints and provides appropriate treatment. Provides participants and caregiver teaching and education. Functions as a member of the Interdisciplinary Team (IDT). Demonstrates the knowledge and skills necessary to assess, plan, care for, and provide services to frail elder participants according to assigned responsibilities and Senior CommUnity Care standards.
1. Performs in person comprehensive history and physical on new Senior CommUnity Care participants. Coordinates with the Interdisciplinary Team to develop a comprehensive plan of care for each participant.
2. Conducts an in person reassessment semi annually and as needed.
3. Integrates the primary care treatment plan into the overall plan of care developed by the Interdisciplinary Team. Interacts with team members to meet emergent and acute need of participants. Participates in discharge planning for acute and long-term placement.
4. Evaluates and treats participants during acute illness.
5. Following consultation with the Medical Director refers participants to medical specialist as indicated.
6. As requested and directed by the Medical Director, manages care of participants in the nursing home: Provides regular visits as dictated by nursing home standards and participant need. Performs telephone contact with nursing home staff as required.
7. Maintains participants' medical record and fulfills Senior CommUnity Care charting and reporting requirements.
8. Functions as a member of the Interdisciplinary Team. Maintains regular attendance at, and participants in Interdisciplinary Team meetings; communicates participant changes, collaborates on plan of care decisions and coordination for twenty-four (24) hour care delivery.
9. Provides relevant participant and caregiver education. Educates and trains participant and caregivers in appropriate care and interventions.
10. Provides staff in-service on a variety of relevant topics.
11. Completion and documentation of appropriate diagnostic coding.
12. Advises the Medical Director in ways and means to establish better accountability of Senior CommUnity Care services to participants and referral sources, keeps Medical Director aware of needed material and human resources as program expands.
13. Assists with the development of, standards of care; performs on-going monitoring and evaluation of patient care practice and service delivery; provides guidance and training to staff regarding medical and quality assurance issues.
14. Acts within the scope of his or her authority to practice.
15. Protects privacy and maintains confidentiality of all company procedures, results and information about employees, participants and families.
16. Follows all Senior CommUnity Care policies and procedures and Occupational Safety and Health Agency (OSHA) safety guidelines.
17. Participates in continuing education classes and any required staff and training meetings. Maintains professional licensure and certifications.
18. Provides information about Senior CommUnity Care Program to interested individuals and groups in adherence to PACE regulations.
19. Practices Universal Precautions and follows all appropriate infection control procedures.
20. Participates in and supports Quality Improvement Initiatives.
21. Performs other duties as required or requested.
QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
2. Must have a valid driver's license, proof of insurance and have means of transportation.
3. Education: Graduate of a school of professional nursing required. Licensed as Registered Nurse (R.N.) in the State of PACE Site. Certified as a nurse practitioner by a national certifying organization recognized by the State Board of Nursing. Certified as a Geriatric Nurse Practitioner (G.N.P.) with prescriptive authority preferred.
4. Experience: A minimum of one year's experience in working with the frail and elderly population required. Two (2) years experience as a nurse practitioner in a geriatric setting desirable. Shall have either training or related experience in the job assigned.
5. Needs to include evidence of having met all PACE organization's position-specific competencies prior to working independently
6. Skills and Knowledge:
* Thorough knowledge of current concepts, theories and practices related to home and community-based care for the elderly and disabled adults.
* Working knowledge of the PACE regulations desired.
* Thorough knowledge of physical, mental and social needs of frail older adults.
* Effective oral and written communication skills.
* Ability to lead and work within the interdisciplinary setting.
* Strong organizational skills.
* Able to manage changing priorities per needs of the PACE program and the agency.
* Ability to utilize computers and other electronic devices for tasks such as timekeeping, in-servicing and documentation.