Registered Nurse. Home Care Coordinator (Older Adults)

Impact Lives, Impact Community

Family Health Centers of San Diego (FHCSD) is passionate about providing exceptional health care to all, especially underserved communities with limited health care options. Founded by a Latina grandmother/community advocate over 50 years ago in Barrio Logan, FHCSD has grown into one of the largest community health systems in the country. With over 90 sites, over 227,000 patients, and over 1.1 million healthcare visits last year, we provide a wide variety of health care and outreach services to a very diverse patient population. We are proud of our mission, our lasting community impact, and the cultural and individual diversity of our staff.

FHCSD’s Program for All-inclusive Care for the Elderly (PACE) is designed to help our patients maintain a high standard of independent living. Our program provides a wide range of supportive services including in-home care, meals, medical equipment, transportation, social services, and social activities. We are currently seeking a Registered Nurse for our Home Care Coordinator position in Oceanside. The RN Home Care Coordinator is responsible for the planning and scheduling of in-home and escort services by FHCSD staff PCAs and CNAs. The RN Home Care Coordinator will work closely with the Home Care LVNs and Home Care staff (CNA/PCA) to ensure all personal care needs of the participants are met.

Location Details

• Hours: Monday through Friday, 8am – 4:30pm
• Address: 2201 Mission Avenue #200, Oceanside CA 92058
• Location Website: https://www.fhcsd.org/pace-oceanside/
• FHCSD PACE Website: https://fhcsdpace.org/services/
• Program Video Overview: https://www.youtube.com/watch?v=j_ijkbygkQw

Responsibilities

• Manage the initial home care assessment for potential PACE participants to include home visits to support environmental and physical assessments.
• Obtains home care services order (e.g. initial evaluation, PRN home visit, discharge home care order) from the PACE clinician’s orders; order must indicate the specific services to be rendered, and whether time-limited, intermittent or on an ongoing basis, and the frequency of the services required by the participant.
• Accurately documents in EHR direct patient services, care coordination, and collaboration with clinicians and other disciplines, maintaining accurate and up-to-date records.
• Initiates care plans and establish the participant's individualized Plan of Care, and medical record baseline, tailored to their unique needs and goals.
• Ensure coordination and completion of reassessments every 6 months at participant’s home for assigned case load.
• Act as a liaison between the participants and the interdisciplinary team members.
• Provide individual health education on the disease process to include verbal and written hand-outs for their reference.
• Coordinates visits, considering the qualifications of the PCA and CNA as well as the participants’ level of care requirements. Notifies participant and/or primary caregiver in advance of changes to scheduling.
• Maintains confidentiality regarding participant, staff, contractor, and organizational information. Non-Essential Job Functions
• Attends and participates in staff meetings, in-services, projects, and committees as assigned.
• Under Home Care manager supervision and guidance may train new staff through shadowing opportunities during patient visits, promoting skill development and consistency in participant’s care delivery.
• Will act as the IDT designee back up in the absence of Home Care Manager.
• Adheres to and supports the center's policies, practices, and procedures.
• Ensures applicable regulatory and departmental standards are adhered to on an on-going basis (CMS, DHCS, etc.).
• Reviews and sign-off on all Care Plans, Initial Assessment, 6-month and Annual Assessments.
• Performs other duties as assigned.

Requirements

• Current California state licensure as a Registered Nurse.
• Previous work experience as a Registered Nurse preferred, but we're willing to train.
• Experience working with elderly or frail populations preferred
• Current American Heart Association healthcare provider CPR (BLS), or Advanced Cardiac Life Support, Advanced Trauma Life Support, or Advance Resuscitation Training.
• Ability and means to travel as needed