Home Care Coordinator - PACE

TriHealth is actively recruiting for a Home Care Coordinator to join PACE of Cincinnati. The PACE Center located in Norwood Ohio. Program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility."

Job Overview:

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.

Job Requirements:

Bachelor's Degree - Nursing Nursing (Preferred)
1 - 2 years of experience with home or community health provider. (Preferred)
Other Current nursing license, if applicable. Preferred 
Basic Life Support (BLS) Certification. Preferred

Job Responsibilities:

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. Completes home care documentation in the PACE EHR in accordance with the federal PACE regulation and organizational policy. 
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. Attends IDT and morning meetings and reports on participant status changes. 
Coordinates durable medical equipment and other assistive devices delivery and maintenance in the home setting. Supports the PACE QI program and participates in PACE QI activities as assigned. 
Assists with case management and care coordination during care transitions and proactively communicates with hospital and long-term care facility case managers regarding participant discharge plans. 
Assists with determining the qualifications, competency, and performance expectations of PACE home care staff and home care contracted providers. Provides orientation, in-service training, and continuing education to PACE home care staff and contracted providers.

Working Conditions:

Bending - Occasionally 
Climbing - Rarely 
Concentrating - Consistently 
Continuous Learning - Consistently 
Hearing: Conversation - Consistently 
Hearing: Other Sounds - Consistently 
Interpersonal Communication - Consistently 
Kneeling - Rarely 
Lifting Lifting 50+ Lbs. - 
Lifting Pulling - Frequently 
Pushing - Frequently 
Reaching - Frequently 
Reading - Consistently 
Sitting - Frequently 
Standing - Frequently 
Stooping - Rarely 
Talking - Consistently 
Thinking/Reasoning - Consistently 
Use of Hands - Frequently 
Color Vision - Frequently 
Visual Acuity: Far - Frequently 
Visual Acuity: Near - Frequently 
Walking - Frequently

TriHealth SERVE Standards and ALWAYS Behaviors

At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:

Serve: ALWAYS... 
• Welcome everyone by making eye contact, greeting with a smile, and saying "hello" 
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist 
• Refrain from using cell phones for personal reasons in public spaces or patient care areas

Excel: ALWAYS... 
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met 
• Offer patients and guests priority when waiting (lines, elevators) 
• Work on improving quality, safety, and service

Respect: ALWAYS... 
• Respect cultural and spiritual differences and honor individual preferences. 
• Respect everyone's opinion and contribution, regardless of title/role. 
• Speak positively about my team members and other departments in front of patients and guests.

Value: ALWAYS... 
• Value the time of others by striving to be on time, prepared and actively participating. 
• Pick up trash, ensuring the physical environment is clean and safe. 
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.

Engage: ALWAYS... 
• Acknowledge wins and frequently thank team members and others for contributions. 
• Show courtesy and compassion with customers, team members and the community