PACE Home Care Coordinator

Primary Accountability

Under the direct supervision of the Center Manager, the FHCN PACE Home Care Coordinator is responsible for the development and implementation of home care services for program participants, including the coordination of all Durable Medical Equipment (DME) and community-based care.

Description of Primary Responsibilities

1. Assesses the home and personal care needs of the frail and elderly population and identifies and works with the Interdisciplinary Team (IDT) to develop specific plans of care.  Initial and periodic assessments to be conducted minimally every 6 months and must be completed prior to the scheduled team meeting.  Receives reports from home care staff and communicates participant changes to IDT members in a timely manner.
2. Schedules and coordinates home care staff -both contract and/or employed, for in-home care delivery and the implementation of all personal care services to ensure that quality services are provided to meet participant needs.
3. Coordinates all DME provisions in a home setting; works with IDT with DME authorization requests.
4. Coordinate 24-hour care delivery.
5. Document participant changes appropriately in the medical records and communicate participant changes to IDT in a timely manner. 
6. Supervise home care staff based in the community.
7. Assist with competencies of home care aides; provide orientation, in-service training, and continuing education of designated staff.
8. Keep up to date on home care standards and best practices.
9. Ability to drive to community locations and residences to provide on-site training and competency checks of home care staff.
10. Provide effective leadership by coordinating and integrating services within the department, with other departments, and with the IDT’s primary functions.
11. Document participant changes appropriately in the medical records and communicate participant changes to IDT in a timely manner. 
12. Participate as a member of the IDT.  Attend staff meetings and take part in participant care planning
13. Other projects and duties as assigned.

Description of Primary Attributes

Professional & Technical Knowledge:

1. Work independently and as an effective member of a team.
2. Work with and treat geriatric patients.
3. Work with IDT on determining home care needs and care planning, including frequency and discharge of home care plans.
4. Schedule and coordinate home care staff to be able to adequately service participants’ home care needs.
5. Ability to assess ADL and IADL dependencies.
6. Communicate home care issues of participants to IDT in a timely manner.
7. Drive to participants’ homes on possibly a daily basis.
8. Only act within the scope of his/her authority to practice.
9. Meet a standardized set of competencies for the specific position description established by FHCN PACE and approved by regulatory agencies before working independently.
10. Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
11. Pass a criminal background which will verify that the candidate is: not excluded from participation in Medicare and Medicaid programs; has not been convicted of criminal offenses related to their involvement in Medicaid, Medicare, other health insurance or health care programs, or social services programs under title XX of the Act; and have not been convicted of physical, sexual, drug or alcohol abuse.
12. Completes orientation competency profile prior to direct participant care.
13. At least 1 year with home or community health provider experience or equivalent experience. 
14. Either have one year of experience working with a frail or elderly population or, in the absence of such experience, receive appropriate training from the FHCN PACE on working with a frail or elderly population upon hiring.

Technical Skills:

1. Ability to prepare more complex documents in Microsoft Word, including creating tables, charts, graphs, and other elements.
2. Ability to use Microsoft Excel to review and compile data, including the use of formulas, functions, lookup tables, and other standard spreadsheet elements.
3. Ability to create basic presentations in Microsoft PowerPoint.

Licenses & Certifications: 

1. Current nursing license, if applicable. Valid CA driver’s license with a good driving record and an acceptable certificate of auto insurance.  
2. Currently certified in cardiopulmonary resuscitation (CPR), if CPR is not current, will be granted 30 days from the date of hire to schedule for the next available CPR certification class provided by FHCN.  

Communications Skills:

1. Job duties require the compilation of information prepared in effective written form, including correspondence, reports, articles, or other documentation.
2. Effectively conveys technical information to non-technical audiences.

Physical Demands and Work Environment: 

Physical demands:  While performing duties of the job, the employee is required to move about the FHCN PACE center and actively engage with the interdisciplinary team and participants. Employees must be able to sit for extended periods of time, as well as work at the computer for long periods.  Employees are required to use their hands and fingers, especially for typing on the computer and using the mouse.  Employees must be able to talk and listen, particularly for phone communications.

Work Environment:  Busy Adult Day Health Center (ADHC) and clinic environment serving the frail elderly with medium to loud noise levels and controlled office temperatures.  Home environments of FHCN PACE participants when conducting needs assessments and supervising home care staff.  Travel time in a vehicle for home visits.

Pay Scale: 

Min Salary Rate: $21.56

Max Salary Rate: $29.75