Position Title: Home-Based Registered Nurse

Department: PACE

Supervisor: Nurse Manager

Status/Hours Per Week: Non-Exempt / 40 hours

Primary Function

The Home-Based Nurse provides initial and semi-annual nursing assessments for home-based participants; develops and implements nursing plan of care: provides medication management, daily nursing treatments, episodic assessments and nursing interventions at the home; collaborates with Primary Care to provide complete nursing services in a safe, secure, accessible environment with skill, dignity and respect; and completes scheduled/episodic nursing visits for Upham’s PACE participants.

Duties & Responsibilities

Complete initial and subsequent semi-annual nursing assessments.
Implement physician’s orders, and document in medical record.
Develop and implement a nursing plan of care for each participant on case load.
Take responsibility for developing and implementing a medication management plan for each participant, i.e. implement physician’s orders, order medications directly from pharmacy, document in medical record, assure administration of medication, provide education and training to participants and/or caregivers when needed to enhance adherence to medication regime.
Take responsibility for coordinating medication deliveries on a timely basis.
Complete scheduled/episodic skilled nursing visits.
Coordinate discharge planning with Center Nurse after ED visits, hospitalizations and nursing home stays.
Provide input in development of participant’s individual care plan.
Maintain medical record documentation.
Act as member of inter-disciplinary team – attending morning meetings and weekly clinical meetings.
Participate in rotating on-call and weekend coverage.
Participate in program development and quality improvement activities.
Perform other duties as requested by Nurse Manager.

Minimum Basic Knowledge

Skilled nursing interventions.
Ability to write and implement nursing care plans.
Computer skills for basic health care entry and documentation.
Solid verbal communication and writing skills in English.

Experience & Qualifications

Licensed Registered Nurse in Massachusetts.
Minimum 1 year of experience working with geriatric population.
Must have a car to visit patients’ homes.
Ability to work with multicultural staff, participants, and caregivers.
Ability to work as a team member in an inter-disciplinary environment.
Bi-lingual language skills in Spanish, Portuguese, and/or Haitian Creole preferred.
Discharge planning experience desirable.

Independent Action

Coordinate with participants, family members, and Upham’s PACE staff, including HHAs, PCWs, and other vendors for service provision as required.
Provide continued education to home health aides, PCWs (Personal Care Workers) as needed.
Plan/schedule skilled nursing visits.

Supervisory Responsibility

None

Define Access Level to PHI: Level 4: Authorized to access full health information. UCC position and job responsibilities involve the provision of patient care and working as a clinical team member. Staff in this category level, although allowed full access, should only access the necessary information for each respective treatment encounter/circumstance.

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Home Based Nurse (PACE)