Position Description

PACE (Program of All-inclusive Care for the Elderly) is a Medicare program for people age 55 or older that provides community-based care and services to people certified by the state as meeting the need for nursing home level of care. The care is provided by an interdisciplinary team of professionals who work with the patient and family to develop a plan of care. The PACE model was designed to provide the following benefits to the frail elderly:
• To stay in familiar surroundings (home vs. institutional setting)
• To maintain autonomy
• To maintain a maximum level of physical, social, and cognitive function






ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Works under the direct and indirect supervision of the Center Manager or designee but is independent in the application of advanced nursing knowledge and skills. Manages complex clinical situations for which he/she is responsible. Supervises both licensed and non-licensed personnel. This position will work primarily in the Southern part of the county.
Other duties may be assigned.

Essential Functions:

• Assessment: Collects patient data and completes required forms with appropriate responses according to unit standards; identifies patient’s overt problems/needs and sets priorities; identifies problems requiring further referral and/or follow-up; interprets and records latest diagnostic results; performs advanced nursing assessment using critical thinking skills.
• Planning Care: Develops a plan of care based on nursing process and which incorporates the plans of other disciplines and continuing care needs; includes the patient/family in developing or revising the plan of care; makes referrals to multidisciplinary support services.
• Implementing/Managing Care: Care provided conforms to accepted practice standards; provides correct treatments/procedures and other care as prescribed and according to patient care standards; demonstrates understanding of age-related characteristics and needs of patients served; explains nursing procedures in appropriate forms; provides discharge teaching; identifies emergency situations and independently initiates advanced therapy; acts as coordinator of patient care with other health care personnel and evaluates patient care measures instituted; understands and demonstrates respect for patient rights and utilizes established mechanisms for management of ethical issues in patient care.
• Evaluation: Records patient care delivered as planned and any variation, with appropriate rationale; makes and records observations related to impending or associated problems.
• Leadership: Using nursing process, delegates nursing care to appropriate personnel; integrates cost effective measures into nursing practice; recognizes unit problems and takes responsibility for documenting same; demonstrates active participation in QI processes; complies with hospital expectations to meet staffing demands based on patient care needs; complies with policies addressing safe working conditions; monitors unsafe working conditions; recognizes inappropriate and/or ineffective patient care management, resolves issue/problem and completes written reports; fulfills call for unit as assigned and adjusts staffing for census (volume) and acuity.
• Conducts initial and periodic assessments
• Communicates participant changes to team members
• Participates in the development of the IDT Plan of Care
• Participates in the coordination of a 24 hour care delivery
• Completes all documentation in the medical record as required

Position Requirements

QUALIFICATIONS, SKILLS AND ABILITIES

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. Successfully complete a Competency Assessment upon hire and receive annual competency assessments.
2. Knowledge of PACE Policies & Procedures.
3. Knowledge of Human Development, including the process of aging.
4. Record keeping and clerical office procedures.
5. Effective oral and written communications.
6. Work efficiently under pressure with deadlines.
7. Work effectively with community/statewide agencies.
8. Maintain department, agency and client confidentiality.
9. Knowledge of Home Health eligibility requirements.
10. Required to participate in utilization review activities as assigned.