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The primary purpose of this position is to uphold and support the mission and core values of SCPP PACE by conducting participant assessments to determine appropriate levels of care and responding promptly to communications from primary care providers and support staff. The role involves performing regular field visits to deliver essential nursing care, including wound care and health assessments, while coordinating with various stakeholders to ensure comprehensive participant support. Additionally, the candidate will document interactions, initiate emergency treatments as needed, and engage in quality improvement initiatives, all within a participant-centered care framework, while adapting to changing workloads and maintaining effective communication with leadership.

Duties and Responsibilities:

• Perform participant assessments in person to determine the appropriate level of care required to safely meet medical needs according to the participants plan of care.
• Respond promptly to calls from PCP, triage, and SCPP support staff. Return calls promptly, prioritizing needs as calls are received. Documents all calls and/or contacts and make follow up contact as needed.
• Complete field visits utilizing full body assessment skills, critical thinking skills, and EMR. Make home visits on a regular basis to provide care and treatment as ordered by the PCP. This may include wound care, IV hydration, lab draws, nurse assessments and other nursing tasks. This will include routine, acute and non-acute visits.
• Provide participant, DPOA, family, friend and/or facility staff education, instruction and support.
• Coordinate and collaborate directly with providers, SCPP staff, DME suppliers, ALF, SNF, paramedics, pharmacy, administration, home care coordinator, hospital, any contractor that SCPP partners with. Initiates emergency treatment if necessary. Initiate and document new orders if indicated including updating PUIs.
• Complete appropriate documentation for reported falls with injury and without injury, threats of suicide, medications errors, incident reports, grievances and other quality measure policies.
• Must care, support, and collaborate with everyone involved in the participant’s care including staff and the participant’s family using the participant centered care model. Actively participate in new employee orientation, ongoing in-service programs, staff meetings, continuous quality improvement, and periodic performance /protocol evaluations and development. Adjust to changes in workload and schedules based on changing team priorities. Keeps the leader informed of problems or issues. Performs other duties as assigned.

Qualifications:

• Bachelor’s degree preferred in Science of Nursing; Associates degree required.
• RN Nursing Diploma or Degree from accredited School of Nursing or University.
• Minimum of one year of experience working with the frail, elderly, or long-term care population.
• Minimum of one year home care experience preferred.
• Minimum of one-year wound care experience preferred.
• Possess current CPR certification by AHA or willing and able to obtain as offered by Senior Care Partners PACE.
• Demonstrates our core values of compassion, integrity, teamwork, and excellence.

Work Environment:

• Has visible presence while working in the center and is subject to frequent interruptions.
• Communicates with staff, participants, caregivers, and other organizations, as necessary.
• Works beyond normal working hours and on weekends and holidays, as necessary.

Minimum Working Requirements:

• Must have reliable transportation, current valid Michigan driver’s license and car insurance.
• Must be 18 years of age or older.
• Must be fully vaccinated, or willing to be fully vaccinated against the following communicable diseases: Influenza, MMR, Varicella, Tdap/Td, Covid-19 and Hepatitis B.