Imagine a center where our seniors can receive transformative health care that will allow them to age at home and in their communities.
At Asian Health Services, we recognize that so many of our elderly patients continue to struggle to get the care they need because of challenges that go beyond the walls of the clinic.
To address these gaps, we’ve found a solution and model of care that integrates the quality care our elders receive at our health center with the most comprehensive support system, like transportation, culturally-inclusive meals, and social activities, our elders deserve.
We are building a Program of All-Inclusive Care for the Elderly (PACE) to bring life-changing, culturally competent care to low-income seniors—supporting them as they age safely and with dignity, right in their communities. Based on the PACE model, SpringLight Health will offer coordinated medical care, transportation, meals, social activities, medication management, and caregiver support—all tailored to each individual’s needs.
The PACE Home Care Coordinator is a member of the PACE Interdisciplinary Team (IDT) and is responsible for completing home care assessments for new PACE participants and home care reassessments for existing PACE participants as part of the PACE IDT care planning process.
The PACE Home Care Coordinator assesses PACE participants for skilled and unskilled home care needs, including durable medical equipment and other assistive devices. Coordinates and supervises all participant home care and durable medical equipment interventions.
The PACE Home Care Coordinator assists the IDT in assessing PACE participants to determine their ability to be safely maintained in a community setting with the services of PACE.
The PACE Home Care Coordinator provides home safety education and training to participants, caregivers, and PACE staff.
Essential Job Functions
Participates as a PACE Interdisciplinary Team (IDT) member and is responsible for completing comprehensive initial home care assessments for new PACE participants and home care reassessments on existing PACE participants as part of the PACE IDT care planning process.
In collaboration with the IDT, develops and implements home care plans for participants, identifying and considering the medical, physical, social, and emotional needs of PACE participants.
Utilizing PACE home care staff and home care contracted providers, schedules and monitors in-home care delivery consistent with individual participant care plans.
Proactively and continuously communicates with PACE home care staff and home care contracted providers and relays participant status changes to IDT members promptly.
Monitors PACE participants for health or psychosocial status changes requiring a home care reassessment. Promptly communicates pertinent changes in participant status to the IDT.
Coordinates durable medical equipment, incontinence supplies, and other assistive devices delivery and maintenance in the home setting.
Assists with determining the qualifications, competency, and performance expectations of PACE home care staff and home care contracted providers.
Completes home care documentation in the PACE EHR in accordance with the federal PACE regulation and organizational policy.
Attends IDT and morning meetings and reports on participant status changes.
Supports the PACE QI program and participates in PACE QI activities as assigned.
Minimum Requirements
Graduate of an accredited School of Nursing.
Bilingual ability (Cantonese and/or Mandarin) and experience providing culturally and linguistically appropriate services.
At least 1 year with home or community health provider experience.
Ability to make home visit and drive to community locations as appropriate and necessary.
Either have one year of experience working with a frail or elderly population or, in the absence of such experience, receive appropriate training from PACE on working with a frail or elderly population prior to providing participant care.
Demonstrate proficiency on a standardized set of core competencies for the PACE Home Care Coordinator position.
Experience working in Electronic Health Records (EHRs).
Before engaging in participant care, be medically cleared for communicable diseases and have up-to-date immunizations and vaccines.
Have not been convicted of criminal offenses involving Medicaid, Medicare, other health insurance or health care programs, or social services programs under title XX of the Act.
Have not been excluded from participating in Medicare and Medicaid programs.
Have not been convicted of criminal offenses pertaining to physical, sexual, drug, or alcohol abuse.
Certifications, Licenses, Registrations
Current Registered Nurse (RN) license in good standing in California (or ability to obtain as required).
BLS certified.
Additional Information
Benefits That Support You We're committed to supporting our team's well-being. Our comprehensive benefits package includes:
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