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SUMMARY:

The Registered Nurse Case Manager (RNCM) of the PACE Southeast Michigan (PACE SEMI) utilizes a systematic approach to nursing practice which incorporates all aspects of the nursing process including, assessment, planning, implementation and evaluation of frail elders with complex needs. The RN demonstrates a direct relationship between nursing interventions and participant outcomes, demonstrates clinical competence and engages in effective patient teaching in areas of prevention as well as treatment. The RN effectively leads or directs licensed and non-professional nursing staff in the coordinated delivery of care to participants of the PACE Southeast Michigan program. The focus of care is one that enhances functional capacity, encouraging autonomy in all aspects of care, and assures coordination of all nursing care.

SPECIFIC DUTIES AND FUNCTIONS:

• The RNCM assesses participants' needs and plans for appropriate nursing care upon the Initial Intake Assessment as well as upon routine Re-Evaluation Assessments.
• The RNCM works and collaborates with the participant and the family, as well as all members of the multidisciplinary Team in developing the participant's plan of care.
• The RNCM maximizes the participant's functional capacity by encouraging autonomy in all aspects of care.
• The RNCM teaches, supervises and counsels the participant, or caregiver regarding nursing care needs and other related problems. The RN utilizes adult learning principles when planning for and implementing educational information to the participants, caregivers or family members.
• The RNCM initiates preventative and rehabilitative procedures or programs as appropriate for the participants' care and safety.
• The RNCM administers medications and treatments, as ordered by the physician/NP, and monitors the participant's response. The RN notifies the appropriate medical personnel of changes in the participant's status.
• The RNCM demonstrates knowledge of the medications he/she administers and instructs the participant/family in safe administration of medication in the home. Assesses for and encourages compliance with medication regimen.
• The RNCM recognizes and understands the significance of abnormal test results and utilizes critical thinking skills when gathering participant data, planning for, and implementing care.
• The RNCM provides safe total patient care to participants with complex health problems with a focus on the individual participant and the family.
• The RNCM maintains all standards of nursing practice and follows hospital policies/procedures for care delivery and medication administration.
• The RNCM leads and monitors licensed and other professional and non-professional staff in the delivery of nursing care to the participant in the home. The RN is responsible for monthly supervision and subsequent documentation of home health aide services provided in the participant's home.
• The RNCM evaluates participant outcomes and or progress toward achieving the objectives/goals of the care plan and communicates this information among other members of the Multidisciplinary Team.
• The RNCM collaborates with the Interdisciplinary Team to revise the plan of care based on changes in the participants' physical or psychosocial status, and initiates actions that are consistent with the changes in status.
• The RNCM participates with patients, families and members of the Interdisciplinary Team to evaluate/measure the individual and group response to nursing care and teaching interventions and documents the outcomes of the problems identified at every scheduled review.
• The RNCM maintains accurate and timely records of participant's functional /health status, progress toward care plan outcomes, revisions to care plans, care given, etc. All charting and documentation is performed in accordance with CSI policies/procedures. The RNCM participates in the collection and documentation of Data PACE information.
• The RNCM advocates to others on behalf of the participant, and demonstrates accountability in resolving participant concerns or issues.
• The RNCM understands, complies with and promotes the Participant Bill of Rights and assesses and works toward achieving high levels of participant satisfaction.
• The RNCM may provide after hours on-call medical assistance on a rotating basis, via phone triage or after hours home visits to participants as needed.
• Schedule requires a rotating on call shift.

KNOWLEDGE, SKILLS AND ABILITIES:

• Must be a Registered Nurse with current Michigan licensure, BSN preferred.
• The RNCM participates in annual, mandatory in-service training and screening, including but not limited to: infection control, TB testing, safety training, and BLS training.
• The RNCM assumes responsibility for self-development through continuing education, utilizing resources within the health care system or elsewhere; the RN promotes professional behavior and growth by serving as a role model within the health team.
• The RNCM must possess a current State of Michigan driver's license and maintain an acceptable driving record.
• The RNCM has the ability to establish and maintain interpersonal and interdepartmental relationships.
• The RNCM has the ability to apply principles of adult learning in planning and implementing educational activities.
• The RNCM has the ability to lead and direct other licensed and non-professional nursing staff in the delivery of care.
• The RNCM participates in and/or facilitates Quality Assurance projects resulting from data results.
• The RNCM assists with the implementation of nursing research studies.
• The RNCM reviews current periodical literature relevant to the general practice of nursing as well as information pertaining to the PACE model of care.
• The RNCM ensures adherence to departmental and external standards in the provision of quality focused care by attendance at professional meetings/committees and review of national standards of practice.
• Must meet a standardized set of competencies (approved by CMS) before working independently.
• Must have one (1) year of experience with a frail or elderly population.

WORKING CONDITIONS:

• Works in the participant's home which is an uncontrolled environment. May be exposed to potentially infectious materials, blood-borne disease pathogens, and hazardous waste. Must be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact
• Driving is required within PACE SEMI catchment area, with possible exposure to extreme temperatures, including heat and cold. Must have reliable transportation available on a daily basis.
• Frequent walking, bending, lifting of forty (40) pounds or more may be needed in the performance of duties.