PACE Home Care Coordinator - East Region (Must have CNA & HHA)

San Ysidro Health•El Cajon, CA

1d•Hybrid

About The Position

The PACE Home Care Coordinator - East Region is a vital member of the Interdisciplinary Team (IDT), working under the supervision of the San Diego PACE Home Care Coordination RN Manager. This role provides essential support to the Home Care Coordination team by conducting home safety evaluations and coordinating various IDT-approved services, including meal delivery, caregiver services, and durable medical equipment (DME) for SD PACE participants. The Home Care Coordinator HHA acts as an advocate for participants' healthcare needs and preferences, ensuring care is delivered in a person-centered and compassionate manner. They work closely with participants, their families, and the IDT to ensure all aspects of unskilled home-based care are coordinated and aligned with participants' goals and preferences. This involves liaising with caregiver agencies and DME suppliers to coordinate schedules, monitor service delivery and quality, and recommend adjustments to care plans as needed.

Requirements

One year of experience with the frail or elderly population.
CNA (Certified Nursing Assistant) and HHA (Home Health Aid) Certifications.
CNA Certificate.
Valid CA driver's license and vehicle insurance.
CPR and First Aid (BLS) certification from the American Heart Association.
Effective oral and written communication skills and the ability to follow written and oral instructions.
Attention to detail when typing and proofing materials.
Ability to communicate effectively and work collaboratively.
Basic computer skills including Microsoft Suite, Outlook, and Excel.
Highly Organized, highly responsive, takes initiative, ability to work collaboratively as a member of the team while independently executing tasks.
Must possess the skills necessary to coordinate and evaluate services for geriatric participants.
Must have a firm understanding of the Home Health Aide scope of practice and operate only within scope.
Professional and personable demeanor to maintain excellent working relationships.
Strong organizational skills with excellent attention to detail.
Ability to solve problems and identify both opportunities and potential challenges.
Maintain confidentiality and discretion and deal effectively and tactfully with staff, patients, and the public.
Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs.
Compliance with all mandated vaccinations and all boosters is a term and condition of employment.

Nice To Haves

HHA (Home Health Aid) Certification

Responsibilities

Coordinate IDT approved meal delivery to client homes.
Coordinate IDT approved Durable Medical Equipment and incontinence supply delivery to client homes.
Coordinate IDT approved caregiver services for participants.
As a member of the IDT, completes the Home Care Coordination care plan at enrollment and semi-annually thereafter.
Conducts pre-enrollment, annual, semi-annual, and change of address home safety evaluations.
Documents and tracks actions, services, and service delivery status updates in designated logs and participant electronic medical records (EMR) in accordance with clinical, DHCS, and CMS regulations and guidelines.
Review progress notes and documentation of the delivery of services, informing the IDT of any gaps in service for reconciliation.
Upload progress notes, reports and care/vendor related documentation to the EMR.
Communicates regularly with participants, their families, and other healthcare providers to ensure coordinated care delivery.
Advocates for participants' healthcare needs and preferences and ensuring that care is delivered in a person-centered and compassionate manner.
Provides support to SD PACE nurses in the coordination and delivery of meals, DME, caregiver services, etc.
Collaborate with the interdisciplinary team members, including physicians, social workers, therapists, and other healthcare professionals, to ensure coordinated care for participants.
Adheres to infectious disease precautions to prevent the spread of organisms.
Attends center staff meetings and in-service educational training programs.
Assists Home Care Coordination RN’s as requested.
Conducts and documents monthly visits for homebound and RCFE participants.
Conducts home visits as needed.
Assists participants with surveys.
Delivers supplies, equipment, grocery bags, and any other items as requested/needed.
Generates and maintains reports on services provided for the participants.
Communicates and works effectively with participants and co-workers.
Participates in interdisciplinary team meetings as needed.
Adheres to SYHC and PACE attendance and punctuality policies and practices.
Follows established PACE and ADHC departmental and position specific policies and procedures.
Attends meetings as required and participates in committees as directed.
Maintains health and safety standards and takes an active role in the Safety and Injury Prevention in the Workplace Program; maintains all records and documentation as required.
Performs other related duties as assigned or requested.