RN- Elder Service Plan
Department: Elder Service Plan
Job Type: Part Time
Job Class: Union
Union Name: WH MNA - WH Mass Nurses Assoc
Work Shift: Days
Date Posted: 09/12/2019
Requisition Number: hrq-91061
The Elder Service Plan of the Cambridge Health Alliance is a Program of All Inclusive Care for the Elderly (PACE). ESP of CHA serves adults 55 years old and older with chronic medical and mental health difficulties with the goals of achieving the highest level of community independence and preventing nursing home placement. ESP of CHA's high functioning interdisciplinary team works to fully integrate and coordinate medical and behavioral health care, community resources, and in home support services.
The clinic/enrollment RN is a member of the ESP Interdisciplinary Team (IDT) who provides nursing care to participants in the clinic who have a wide variety of diagnoses. The clinic nurse demonstrates expertise in assessment, clinical decision-making and clinical practice. Nursing care is reflective of the participant's plan of care. Participant's status, new problems and/or problems indicating a significant change in status are communicated to the IDT through established methods of communication, e.g., morning meeting, care plan meetings, etc.
The clinic nurse contributes to the assessment, development, implementation and re-evaluation of participant's care plan processes. Participates with the enrollment team by performing initial assessments, case management, coordination of initial home care needs i.e. medication reconciliation, warm hand offs and onboarding of participants. Cross-cover in telephone triage as required.
Highly developed geriatric assessment and clinical skills required.
At least one year of clinical experience in geriatrics required.
At least one year of home care experience required.
Current RN MA licensure required.
BSN strongly preferred; BSN required within 1 year of hire date for newly hired RNs
American Heart Association BLS certification required
Reliable transportation to make daily home visits in ESP service area required. Phlebotomy skills required.
Knowledge of PACE (Program of All-inclusive Care for the Elderly) and its national model preferred