PACE Home Care Coordinator (Vista)

Position Summary: As a collaborative member of the IDT, and under the supervision of the PACE Home Care Coordination RN Manager, the PACE Home Care Coordinator HHA provides foundational support to the Home Care Coordination team. This role conducts home safety evaluations, coordinates and monitors IDT approved services, such as the delivery of meals, caregiver services and DME (durable medical equipment) for San Diego PACE participants. The Home Care Coordinator HHA is an advocate for participants' healthcare needs and preferences, ensuring that care is delivered in a person-centered and compassionate manner; working closely with participants, their families, and the interdisciplinary team to ensure that all aspects of unskilled homebased care is coordinated and aligned with the participants' goals and preferences. They liaise with, care giver agencies, DME suppliers, etc. to coordinate schedules, monitor the delivery and quality of services/care provided, and make recommendations for adjustments to care plans as needed. 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. As a member of the IDT, completes the Home Care Coordination care plan at enrollment and semi-annually thereafter. Conducts pre-enrollment, annual, semi annual, and change of address home safety evaluations Documents and tracks 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. Communicates regularly with participants, their families, and other healthcare providers to ensure coordinated care delivery. Advocates for participants' healthcare needs and preferences and ensuring that care is delivered in a person-centered and compassionate manner. Provides 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. Adheres to infectious disease precautions to prevent the spread of organisms. Attends center staff meetings and in-service educational training programs. Assists Home Care Coordination RN's as requested. Conducts and documents monthly visits for homebound and RCFE participants. Conducts home visits as needed. Assists participants with surveys. Delivers supplies, equipment, grocery bags, and any other items as requested/needed. Generates and maintains reports of services provided for the participants. Additional Duties and Responsibilities: Communicates and works effectively with participants and co-workers. Participates in interdisciplinary team meetings as needed. Adheres to SYHC and PACE attendance and punctuality policies and practices. Follows established PACE and ADHC departmental and position specific policies and procedures. Attends meetings as required and participates in committees as directed. Maintains health and safety standards and takes an active role in the Safety and Injury Prevention in the Workplace Program; maintains all records and documentation as required. Performs other related duties as assigned or requested. Minimum Qualifications: Must possess a Home Health Aide certificate 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 (Minimum level of education): Must have CNA and California Department of Public Health Home Health Aide certificate (HHA). Must have CPR and First Aide certification form the American Heart Association. Experience Required (Minimum level of experience): 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: Continuous standing/walking/twisting. Occasionally lifts pushes and/or transfers participants. Exposed to elements of health-related work (accidents, injuries and illness). Travel to SYH and San Diego PACE sites and to meetings as needed Universal 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.