BASIC PURPOSE & SCOPE:
Under the direction of the Program Director, the Home Care
Coordinator is responsible for, but not limited to, day to day licensed site
and service supervision, coordination of home care assessments and home care
management, PACE clinical eligibility assessments, supervision of nursing and
services staff, and provision of skilled nursing services.
- Provides orientation, annual physical assessments, in-service education, supervision and evaluation to nursing staff and services staff as assigned. Supervision and evaluation includes the direct oversight and documentation of performance in the home, coordinating supervisory matters relating to scheduling and service delivery.to assess, advise, and teach participants and coordinate the scheduling of enrollee care.
- Ensures delivery of services within the parameters defined by the participant plan of care and agency policy and procedure, tracking and monitoring that required supervisory/assessment visits are completed for assigned participants and as requested for paraprofessional staff and develops and updates the plan of care and required documentation.
- Provides direct hands on nursing home care to participants and families, as defined in the IDT plan of care.
- Works as a member of the intake and enrollment team to assess for clinical eligibility of prospective new enrollees per state requirement and semiannually thereafter.
- Conducts PACE and LHCSA home care assessment for pre-enrollment and periodic assessments of each enrollee and coordinates home care in accordance with state and federal regulations and each agencies’ policies and program regulations.
- Participates in the development and revision of the enrollee’s plan of care as a member of the Interdisciplinary Team.
- Coordinates the provision of home care services and DME required to meet participant home health care needs in accordance with agency provider network.
- Implements plan of care and completes participant/patient home care visits as necessary and delivers nursing care services in accordance with the plan of care.
- Provides professional mentoring and monitoring of all home care nursing staff assigned to the site, including subject to call.
- Provides day-to-day coordination of nursing activities at assigned site.
- Works with the Program Director to control and prioritize utilization of home care resources to reflect actual enrollee home care needs.
- Effectively communicates with participants and their families regarding home care needs, patient teaching, grievances and other concerns.
- Monitors home care documentation to ensure care coordination and comprehensive medical record.
- Obtains and tracks equipment, supplies and services used in the home such as durable medical equipment and incontinence supplies as reflected in the care plan.
- Participates in on-call coverage after center hours to assess, advise, and teach participants and coordinate the scheduling of enrollee care.
- Communicates changes in participant status to IDT and appropriate LHCSA nursing and scheduling staff.
- Along with the IDT, works with acute and sub-acute discharge planners to coordinate safe discharge back home or to alternate placement with necessary home health care and DME with the goal of minimizing hospital lengths of stay as appropriate.
- Coordinates with clinic staff, pharmacy and LHCSA to ensure appropriate administration of medications at home.
- Counsels and guides individuals and families towards recognition and solution of physical, emotional and environmental health problems.
- Makes referrals to other services when enrollee conditions or situations require the service of other professional disciplines or the products or services of outside companies or agencies. This includes, but is not limited to, volunteer agencies, loan closets, therapy services, support groups, etc.
- May participate in joint team/family meeting to discuss current nursing and home care activities, concerns and suggestions for care plan update and/or revisions.
- Establishes and maintains cooperative working relationships with other program staff, contact agencies and outside organizations.
- Participates in quality management program activities, including contract agency and peer reviews.
- Keeps confidentiality of client records, reports and discussions.
- Participates in formulation and maintenance of Total Senior Care, Inc. policies and procedures.
- Participates in Total Senior Care Committees as requested by the Program Director. May chair committees and task forces.
- Advises the Program Director in ways and means to establish better accountability of Total Senior Care, Inc. services to participants and referral sources.
- Maintains flexibility in schedule and responds to unexpected emergencies and changes in workload in order to fulfill responsibilities.
- Utilizes supplies and equipment economically.
- Informs the Program Director of “unusual occurrences.”
- Identifies nursing and home care service delivery problems and uses good judgment in their solution.
- Is professional in appearance in manner in the clinical area; recognize own limits and seek help and guidance from the Program Director as appropriate; responds in a positive manner to constructive criticism; serves as a role model for students and staff members.
- Optionally holds membership in professional organizations.
- Maintains applicable licensure and certification and pursues professional growth through continuing education process. Maintains clinical excellence, consistently advancing knowledge base and clinical skill sets.
- Adheres to and reflects organizational values in daily work.
- Serves on agency committees as may be assigned.
- Maintains an obligation to report wrongdoing/violation of agency policies, applicable federal, state, and local laws, and rules and regulations pertaining to agency operations, to immediate supervisor or identified compliance officer.
- Completes all mandatory inservice education programs and completes any other additional inservice hours that are minimally required for the position.
The above examples of work may not be a complete statement
of all assignments that may be inherent to the position. Other duties may be
assigned as deemed necessary and appropriate by the Administrator/CEO.
- Bachelor’s degree in Nursing, or Associate’s degree in Nursing and appropriate additional training and experience in home care, long term care and/or PACE.
- Five or more year’s thorough knowledge of current community health nursing practice. Minimum 1-year experience working with the frail elderly.
- Nursing, geriatrics, health care and home health. Interdisciplinary teamwork, ability to work effectively with culturally, economically and educationally diverse populations, and form positive interpersonal relations in dealing with a wide range of staff and clients essential.
- License and current registration to practice as Registered Nurse in New York State.
- Working knowledge of home and community based nursing programs. Skilled in the application of current nursing procedures, assessment, and techniques of patient care. Ability to communicate effectively. Ability to establish and maintain cooperative working relationships. Ability to supervise others in a direct, firm and understanding way. Ability to accept and utilize guidance. Ability to perform duties in accordance with ANA Code for professional nurses. Acceptable physical and mental health to carry out the responsibilities of the position.
- Acceptable driver’s license and use of automobile during work hours.