PACE Home Care Coordinator

Position Summary

As a collaborative member of the IDT, and under the supervision of the PACE Home Care Coordination RN Manager, this role provides foundational support to the Home Care Coordination team. The responsibilities include conducting home safety evaluations, coordinating and monitoring IDT-approved services such as the delivery of meals, caregiver services, and DME (durable medical equipment) for San Diego PACE participants. The coordinator acts as an advocate for participants' healthcare needs and preferences, ensuring that care is delivered in a person-centered and compassionate manner. This involves working closely with participants, their families, and the interdisciplinary team to ensure that all aspects of unskilled home-based care are coordinated and aligned with the participants' goals and preferences.

Essential Functions of the Job

• 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.
• Complete the Home Care Coordination care plan at enrollment and semi-annually thereafter.
• Conduct pre-enrollment, annual, semi-annual, and change of address home safety evaluations.
• Document and track 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.
• Communicate regularly with participants, their families, and other healthcare providers to ensure coordinated care delivery.
• Advocate for participants' healthcare needs and preferences, ensuring that care is delivered in a person-centered and compassionate manner.
• Provide support to 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.
• Adhere to infectious disease precautions to prevent the spread of organisms.
• Attend center staff meetings and in-service educational training programs.
• Assist Home Care Coordination RNs as requested.
• Conduct and document monthly visits for homebound and RCFE participants.
• Conduct home visits as needed.
• Assist participants with surveys.
• Deliver supplies, equipment, grocery bags, and any other items as requested/needed.
• Generate and maintain reports of services provided for the participants.

Additional Duties and Responsibilities

• Communicate and work effectively with participants and co-workers.
• Participate in interdisciplinary team meetings as needed.
• Adhere to SYHC and PACE attendance and punctuality policies and practices.
• Follow established PACE and ADHC departmental and position-specific policies and procedures.
• Attend meetings as required and participate in committees as directed.
• Maintain health and safety standards and take an active role in the Safety and Injury Prevention in the Workplace Program; maintain all records and documentation as required.
• Perform other related duties as assigned or requested.

Minimum Qualifications

• Must possess a Home Health Aide certificate and CNA certificate.
• 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.
• Must be able to communicate clearly and function well in a team environment.

Job Requirements

Education Required

• Must have CNA and California Department of Public Health Home Health Aide certificate (HHA).
• Must have CPR and First Aid certification from the American Heart Association.

Experience Required

• One year experience with the frail or elderly population.
• Valid California Driver's License.

Technical Knowledge and Skills Required to Perform the Job

• Basic computer skills, Microsoft, Outlook, Excel.

Working Conditions and Physical Requirements

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.

HIPAA/Compliance

• Maintain privacy of all patients, employee, and volunteer information and access such information only on a need-to-know basis for business purposes.
• Comply with all regulations regarding corporate integrity and security obligations. Report unethical, fraudulent, or unlawful behavior or activity.

OSHA Compliance

Comply with all regulations and required schedules regarding OSHA training.

PPD Compliance

Required health screening to be performed annually.

Policies and Procedures Compliance

• Responsible for following all *** policies and procedures.

Meal Period Compliance (Non-exempt employees only)

Punch out before 5 hours from the start of shift for meal periods.

Sexual Harassment Training

Comply with all regulations and required schedules regarding sexual harassment training.

Customer Service Training

Participate in customer service training as required.