Serves as a member of the PACE Interdisciplinary Team. Participates as a member of the Interdisciplinary Team in the planning, implementation and evaluation of care plans that meet the objectives, standards and policies of the PACE model of care. Demonstrates proficiency in administering nursing care in a professional and respectful manner with the goal of assisting frail elders to remain living in the community for as long as they can do so safely.
- Provides direct care to participants. Completes initial and periodic assessments for participants, develops and revises care plans according to emergent and pre-existing needs.
- Collects the necessary medical and social information to ensure comprehensive decisions are made which ensure the safety and well being of participants.
- Monitors clinic care & service delivery to ensure conformance with established quality assurance and operational policies, procedures and standards.
- Remains attentive to participants’ health status and social functioning; assists with identification of overt problems/needs and sets priorities; treats problems requiring immediate referral and/or follow-up; and interprets and records latest diagnostic results, as indicated.
- Coordinates with the interdisciplinary team to develop a comprehensive care plan for each participant incorporating immediate and continuing care needs, including the participant and family perspective.
- Actively takes part in implementing a summary on each client to help the state determine Nursing Home Level of Care.
- Ensures all tests, lab work and diagnostic studies ordered by the Physician have been carried out.
- Coordinates all medication, including the stocking of non-prescription medications, the ordering of prescription medications, the administering of medication in the PACE Center, and the monitoring of participant compliance. Arranges for delivery of needed medications and supplies to the participant’s home.
- Provides education and consultation to participants and caregivers in regards to care plan, nursing treatments and medications.
- Communicates participant’s condition to primary care givers, physician and multidisciplinary team.
- Builds strong relations with participants, caregivers, families and community providers so communication and coordination occurs in a manner that facilitates optimal care and financial oversight.
- Participates in after-hour visits.
- Ability to pass a fit test. Position requires mask where seal is critical. Incumbent is required to not have facial hair that interferes with a tight seal of the respirator.
- Other duties as required.
Team Lead/CHARGE RN added responsibilities: (If applicable)
- Attend Charge Nurse meetings monthly and communicate feedback to site
- Train and oversee students
- Provide direction, instructions and guidance to team.
- Manage workflow of day-to-day operations.
- Create reports to update team projects/performance.
- Coach, facilitate, motivate and solve team problems
- Registered Nurse currently licensed in the Commonwealth of MA.
- Minimum of two (2) years experience with the geriatric population.
- Proficient in the use of Microsoft Office tools.
- Ability to travel locally on a frequent basis in a personal vehicle.
- Ability to be able to quickly recognize situations/problems before they become acute, and to be able to implement effective solutions and understand consequences.