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.
