Job Summary The PACE Home Care Coordinator is a member of the PACE Interdisciplinary Team (IDT) and is responsible for completing home care assessments for new PACE participants and home care reassessments for existing PACE participants as part of the

PACE IDT

care planning process. The PACE Home Care Coordinator assesses PACE participants for skilled and unskilled home care needs, including durable medical equipment and other assistive devices. Coordinates and supervises all participant home care and durable medical equipment interventions. The PACE Home Care Coordinator assists the IDT in assessing PACE participants to determine their ability to be safely maintained in a community setting with the services of PACE. The PACE Home Care Coordinator provides home safety education and training to participants, caregivers, and PACE staff. Position Responsibilities § Participates as a PACE Interdisciplinary Team (IDT) member and is responsible for completing comprehensive initial home care assessments for new PACE participants and home care reassessments on existing PACE participants as part of the

PACE IDT

care planning process. § In collaboration with the IDT, develops and implements home care plans for participants, identifying and considering the medical, physical, social, and emotional needs of PACE participants. § Utilizing PACE home care staff and home care contracted providers, schedules and monitors in-home care delivery consistent with individual participant care plans. § Proactively and continuously communicates with PACE home care staff and home care contracted providers and relays participant status changes to IDT members promptly. § Monitors PACE participants for health or psychosocial status changes requiring a home care reassessment. Promptly communicates pertinent changes in participant status to the IDT. § Coordinates durable medical equipment and other assistive devices delivery and maintenance in the home setting. § Assists with case management and care coordination during care transitions and proactively communicates with hospital and long-term care facility case managers regarding participant discharge plans. § Assists with determining the qualifications, competency, and performance expectations of PACE home care staff and home care contracted providers. Provides orientation, in-service training, and continuing education to PACE home care staff and contracted providers. § Completes home care documentation in the

PACE EHR

in accordance with the federal PACE regulation and organizational policy. § Attends IDT and morning meetings and reports on participant status changes. § Supports the PACE QI program and participates in PACE QI activities as assigned. Experience & Education § Licensed Vocational Nurse License § Current nursing license, if applicable § At least 1 year with home or community health provider experience. § Ability to drive to community locations to provide on-site training and home care staff competency checks on contracted home care providers. § Either have one year of experience working with a frail or elderly population or, in the absence of such experience, receive appropriate training from PACE on working with a frail or elderly population prior to providing participant care. § Demonstrate proficiency on a standardized set of core competencies for the PACE Home Care Coordinator position. § Experience working in Electronic Health Records (EHRs). § CMS required) Before engaging in participant care, be medically cleared for communicable diseases and have up-to-date immunizations and vaccines. § Have not been convicted of criminal offenses involving Medicaid, Medicare, other health insurance or health care programs, or social services programs under title XX of the Act. § Have not been excluded from participating in Medicare and Medicaid programs. § Have not been convicted of criminal offenses pertaining to physical, sexual, drug, or alcohol abuse. § BLS certified.

Pay:

$62,000.00 - $74,000.00 per year

Work Location:

In person