Trinity Health RN - MDS - Mercy LIFE PACE in West Springfield, Massachusetts
Are you committed to keeping frail elders in the community? Want to work with a truly integrated team? PACE is a model of care that includes an inter-disciplinary team working together to problem-solve and create solutions to help elders remain living at their home. As part of the Interdisciplinary Team (IDT), assesses and monitors participants’ health status, provides nursing care, administers prescribed medications, educates and counsels participants and families, in collaboration with primary care physician and other team members. Informs the IDT of the medical, functional, and psychosocial condition of each participant, remaining alert to pertinent input from other team members, participants, caregivers, as well as documenting changes in a participant’s medical record consistent with documentation policies established by the medical director.
PRIMARY JOB RESPONSIBILITIES AND DUTIES:
Demonstrates, promotes and integrates the Mercy LIFE Mission and core values by performing the following duties:
Works with In-Home Services Manager to perform initial client assessment; confers with the IDT team and physician in the development of the Plan of Care (POC); implements the POC as decided upon by the IDT team, makes changes to life plan per approval of the IDT team.
Provides services requiring substantial knowledge and skills in accordance with the POC, and accepted standards of professional practice.
Provides skilled assessments of client/family needs, physical and emotional conditions, and responses to the POC. Communicates changes in condition to the In-Home Services Manager, physician and other IDT members.
Provides skilled supportive and restorative nursing care to participants as ordered, re-evaluating their plan of care and health status on an on-going basis. Provides health counseling to participants and their families on an individual or group basis as needed.
Maintains and submits documentation as required. Prepares and submits documentation of client assessments, summaries, care plans, family meetings, and progress notes according to Mercy LIFE policy.
Provides training and clinical supervision to aides, and provides orientation programs as directed by In-Home Services Manager.
Assists the In-Home Services Manager to serve as a liaison between Mercy LIFE and contracted Home Health Agencies and Personal Care Agencies. Controls and prioritizes utilization of homecare staffing needs to reflect actual enrollee’s homecare needs.
Performs initial and annual assessments of participants in their home environment to determine their individual needs, and coordinates POC with care-giving resources. Coordinates with the IDT to develop a POC for each participant.
Functions as a member of the IDT. Maintains regular attendance at, and participates in IDT meetings, communicates participant changes, collaborates on POC decisions and coordination of 24 hour care delivery.
Provides on-call coverage on a rotating basis with other staff to troubleshoot, advise and coordinate participant care.
Provides clinic coverage as needed.
REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:
Education - Graduate of a state accredited hospital or collegiate nursing program. Registered Nurse currently licensed in the state of Massachusetts. Current Cardio-Pulmonary Resuscitation (CPR) registration required.
Experience - Familiarity of current medical/nursing trends and practices. Two (2) years’ nursing experience, including one (1) year working with the frail or elderly required.
Specialized Skills - Must have excellent assessment skills. Experience in interdisciplinary care planning conferences is beneficial. Must possess good leadership, decision-making and interpersonal skills and be able to interact with staff, family, participants and other disciplines involved in care.
Must have a valid driver’s license, proof of insurance and have means of transportation.
Must be able to safely perform the essential job functions with or without reasonable accommodation.
Must be physically able to perform assessments on residents in sitting, lying and standing positions. Must be able to lift greater than 50 pounds. Must be able to communicate effectively in the English language.
Requires exposure to the elements while traveling between patients’ homes. Requires working in patients’ homes with varying degrees of dust, dirt and clutter.
Requires working with equipment or performing procedures where carelessness would probably result in minor cuts, bruises or muscle pulls.
Requires exposure to blood and various body fluids that requires caution and use of established safety guidelines and equipment.
May require lifting, standing, bending, transferring, stooping, stretching, walking, pushing, pulling; partial or complete assistance with activities of daily living without assistance from another health care worker or significant other.
Will be exposed to varying temperatures and humidity levels. Will be primarily indoors, in a well-lighted and ventilated area.
May be exposed to infectious waste, needles and body fluids.
Reports to the Manager of In-Home Services.
Has no responsibility for the direct supervision of any employees.
We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
Job Number: 00142468
Location: West Springfield, MA
Organization Name: Trinity Health PACE
Facility: SPMA - Hillside Prov
Employment Type: Full time
Shift: Day Shift