Job Summary: Responsible for the development and implementation of homecare services (including the coordination of all Durable Medical Equipment and home care) to the Senior Total Life Care (TLC) participants in a home and community-based model of care. Under the direct supervision of the Center Manager and indirect supervision of the Chief Operating Officer.

Education: Associate degree in nursing preferred but not required.

Experience: At least 1 year as an RN, preferably in either home or community health but not required. Minimum of 1 years’ experience working with the frail elderly population preferred.

Number and Type of Employees Supervised (optional): None

Licensure, Registry or Certification Required: Licensed RN in NC, current, valid NC driver's license and vehicle.

Special Training: Must be able to work effectively in a team environment. Must possess excellent communication, interpersonal and conflict resolution skills. Must be able to treat geriatric patients. Only act within the scope of his or her authority to practice. Meet a standardized set of competencies established by Senior TLC and approved by CMS before working independently.

Immunizations: Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact

Ages of Patients Rendered Care:

• Using the nursing process, assess the home care needs of a frail elderly population, and identifies and develops specific plans of care. Conducts initial and periodic assessments that must be completed prior to the scheduled team meeting at a minimum of every 6 months. Communicates participant changes with team members.
• Coordinates 24-hour care delivery and the implementation of all home care services which includes personal care services to ensure that quality services are provided to meet participant needs.
• Coordinates and authorizes all Durable Medical Equipment (DME). Manages home supplies such as incontinence, diabetic, colostomy, nutritional, and other supplies. Also manages services such as Life Alerts and electronic medication reminder systems.
• Reconciles invoices for personal care service hours and home supplies.
• Performs acute, in-home visits as requested by primary care provider and/or supervisor.
• Coordinates any DME for participants in the nursing facilities according to program standards. Includes interaction with other facility staff. Assists with discharge planning efforts from nursing facility to home and arranges appropriate care as part of discharge plan as approved by IDT.
• Supports his/her Interdisciplinary Team and promotes unity among the team while interacting with the team, other co-workers, and/or participants. Participates, collaborates, and contributes as a member of the Interdisciplinary team, emphasizing teamwork and collaboration in all clinic and Interdisciplinary team interactions.
• Participates in participant care planning including the implementation of SMART goals/interventions for the participants’ care plans and enters all care plan information in a timely manner as per organizational protocols. Updates participants’ care plans appropriately throughout the reassessment period.
• Works with Social Worker to provide community resources for participant needs.
• Provides nursing triage through the on-call nurse rotation schedule.
• Performs other nursing tasks as designated by supervisor.
• Supports the Senior TLC mission to encourage and support the quality of life of seniors wishing to continue living in the community; its vision to be the preferred provider of individualized care for seniors in the community; and its values of respect, integrity, accountability, compatible goals, and compassionate care.
• Other duties as assigned.