Home Care RN

ArchCare•New York, NY

About The Position

The Home Care RN assesses participants’ physical and functional needs, psychosocial status, home safety, and caregiver burden. The RN completes required assessments and documentation, including UAS assessments, problem lists, interventions, and New York State assessment tools. The RN develops and implements home care plans in collaboration with participants, caregivers, and the interdisciplinary team (IDT), monitors outcomes, and updates the team on participants’ progress and changing needs. The RN provides initial and ongoing assessments for participants in the PACE program, coordinates care with primary care providers and center nurses, and directs home health aides and geriatric caregivers in providing personal care, nursing rehabilitation tasks, and other home-based services. The RN coordinates medication delivery and administration assistance, supports advance-care planning education, and evaluates participants’ and families’ understanding of nursing needs and their ability to perform self-care or allowable nursing tasks. The role includes documenting changes in participants’ conditions and care provided, traveling to participants’ homes and other facilities to deliver care as appropriate, managing nursing plans for a caseload, and maintaining productivity to meet program goals. The RN serves as a liaison to community agencies, participates in PACE and ArchCare Senior Life meetings and quality improvement activities, and maintains flexibility to respond to emergencies and changing workloads. The RN must meet the position’s standardized competencies, established by the PACE organization and approved by CMS, before working independently.

Requirements

Associate degree in Nursing.
At least one year of nursing experience in a health care setting.
One year of experience with a frail geriatric population in a long-term care or home care setting.
One year of experience with a frail or elderly population.

Nice To Haves

Bachelor’s degree in nursing.

Responsibilities

Assess participants’ physical and functional needs, psychosocial status, home safety, and family caregiver burden.
Complete assessment documents, including UAS, problem lists, interventions, and other required documentation for data collection and quality assessment and performance improvement.
Develop and implement home care components and collaborate with the interdisciplinary team to create comprehensive plans of care aligned with participant and caregiver needs and mutually acceptable goals.
Monitor care effectiveness and outcomes, keep the team informed of participant progress and needs, and revise goals and care approaches with the interdisciplinary team.
Conduct initial home care assessments for new participants and reassess at appropriate intervals according to PACE standards and individual needs.
Complete New York State-required assessment tools according to the schedule established by the interdisciplinary team.
Coordinate with primary care providers and center nurses regarding medication, ancillary tests, and functions such as home blood draws.
Direct Home Health Aides and Geriatric Caregivers in providing personal care, nursing rehabilitation tasks, and other home-based work.
Coordinate medication delivery and administration processes for participants who need assistance at home.
Coordinate with the Primary Care team to obtain advance directives and educate participants and families about advance-care planning options and rights.
Educate participants and families about nursing needs and assess their ability to perform self-care or allowable nursing tasks.
Document changes in participants’ conditions and care provided, and ensure compliance with PACE documentation requirements and agency policies.
Travel to participants’ homes and other facilities to provide direct care as appropriate and within applicable regulations.
Manage home care nursing plans for a caseload and maintain productivity sufficient to meet program goals.
Assist interdisciplinary team members, including physicians, in understanding participants’ nursing, self-care, and functional needs related to their health problems.
Use appropriate community resources and serve as a liaison between the program and community agencies.
Provide nursing services in accordance with New York State Department of Education requirements, nursing scope of practice, and agency policies and procedures.
Assume responsibility for continued professional growth, including participation in in-service programs.
Participate in selected programs with community agencies.
Regularly inform the interdisciplinary team of each participant’s medical, functional, and psychosocial condition, and remain attentive to input from team members, participants, and caregivers.
Document participant condition changes in the medical record according to documentation policies established by the medical director.
Participate in PACE and ArchCare Senior Life meetings and activities, including interdisciplinary team and family meetings, staff meetings, training, rehabilitation services meetings, and quality improvement activities.
Maintain schedule flexibility and respond to emergencies and workload changes.
Meet standardized competencies for the position established by the PACE organization and approved by CMS before working independently.
Perform other related duties as required.