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 include: assessing participants' needs and planning for appropriate nursing care upon the Initial Intake Assessment as well as upon routine Re-Evaluation Assessments; working and collaborating with the participant and the family, as well as all members of the multidisciplinary team in developing the participant's plan of care; maximizing the participant's functional capacity by encouraging autonomy in all aspects of care; teaching, supervising and counseling the participant, or caregiver regarding nursing care needs and other related problems; initiating preventative and rehabilitative procedures or programs as appropriate for the participants' care and safety; administering medications and treatments, as ordered by the physician/NP, and monitoring the participant's response; demonstrating knowledge of the medications he/she administers and instructing the participant/family in safe administration of medication in the home; recognizing and understanding the significance of abnormal test results and utilizing critical thinking skills when gathering participant data, planning for, and implementing care; providing safe total patient care to participants with complex health problems with a focus on the individual participant and the family; maintaining all standards of nursing practice and following hospital policies/procedures for care delivery and medication administration; leading and monitoring licensed and other professional and non-professional staff in the delivery of nursing care to the participant in the home; evaluating participant outcomes and or progress toward achieving the objectives/goals of the care plan and communicating this information among other members of the Multidisciplinary Team; collaborating with the Interdisciplinary Team to revise the plan of care based on changes in the participants' physical or psychosocial status, and initiating actions that are consistent with the changes in status; participating 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; maintaining accurate and timely records of participant's functional /health status, progress toward care plan outcomes, revisions to care plans, care given, etc.; advocating to others on behalf of the participant, and demonstrating accountability in resolving participant concerns or issues; understanding, complying with and promoting the Participant Bill of Rights and assessing and working toward achieving high levels of participant satisfaction; providing after hours on-call medical assistance on a rotating basis, via phone triage or after hours home visits to participants as needed; and schedule requires a rotating on call shift.
Knowledge, skills, and abilities include: being a registered nurse with current Michigan licensure, BSN preferred; participating in annual, mandatory in-service training and screening; assuming responsibility for self-development through continuing education; possessing a current State of Michigan driver's license and maintaining an acceptable driving record; establishing and maintaining interpersonal and interdepartmental relationships; applying principles of adult learning in planning and implementing educational activities; leading and directing other licensed and non-professional nursing staff in the delivery of care; participating in and/or facilitating Quality Assurance projects; assisting with the implementation of nursing research studies; reviewing current periodical literature relevant to the general practice of nursing as well as information pertaining to the PACE model of care; ensuring adherence to departmental and external standards in the provision of quality focused care; meeting a standardized set of competencies before working independently; and having one (1) year of experience with a frail or elderly population.
Working conditions include: working in the participant's home which is an uncontrolled environment; being exposed to potentially infectious materials, blood-borne disease pathogens, and hazardous waste; being medically cleared for communicable diseases and having all immunizations up-to-date before engaging in direct participant contact; driving required within PACE SEMI catchment area, with possible exposure to extreme temperatures, including heat and cold; having reliable transportation available on a daily basis; and frequent walking, bending, lifting of forty (40) pounds or more may be needed in the performance of duties.