Community Health Nurse

Under the direction of a Nurse Manager, the PACE Community Health Nurse (PCHN) provides skilled care and routine clinical nursing assessment visits to PACE members and families utilizing all elements of the nursing process and in compliance with applicable laws, regulations, and agency policies. The PCHN primarily visits members in their homes in the community but can also visit members in the PACE center, hospitals, nursing homes, and other alternate settings as deemed necessary for care coordination consistent with the PACE model of care.

The PCHN is a core interdisciplinary team (IDT) member who is assigned to a PACE member in compliance with CMS PACE regulatory requirements.

• Carries out the agency’s mission, philosophy, goals, and objectives within guidelines of Agency policy and position function.
• Interprets and implements the Agency’s philosophy to staff and members of the community.
• Assumes responsibility for assignments given, seeks supervision appropriately, and performs within the limits of their education and experience.
• Knows and conforms to the law governing the practice of professional nursing and provides professional nursing care using all elements of the nursing process.
• Assesses and evaluates the health care needs of patients and families with consideration regarding physiological, psychological, social, and environmental factors.
• Identifies a complete, accurate, and logical Uniform Assessment System (UAS) for NY and appropriate sequencing of diagnoses in collaboration with the PCP to maintain compliance with state and federal regulations.
• Participates in mandatory PACE comprehensive care planning meetings routinely as required by PACE regulations.
• Collaborates with all members of the IDT in developing a comprehensive care plan based on member‑specific needs, physician orders, UAS‑NY CAPS, other IDT assessments, members’ specific parameters, and identified goals that are respectful of member, family, community, and agency resources.
• Implements the nursing care plan and revises it whenever necessary by regularly assessing, observing, and evaluating the patient’s condition, needs, and response to care and making appropriate nursing judgments and decisions for care plan revision.
• Initiates and applies appropriate preventative, therapeutic, and rehabilitative nursing procedures and techniques.
• Administers medications and treatments as prescribed by the PCP.
• Independently performs skilled nursing procedures and techniques based on the changing nursing needs that the member requires.
• Teaches the patient and family/caregivers self‑techniques whenever appropriate and provides instruction regarding medication, diet, safety, and treatment modalities in accordance with the plan of care.
• Recognizes and utilizes additional opportunities for health counseling/education with patients, families, and other caregivers and provides them with information that will facilitate decisions regarding the promotion, maintenance, and restoration of health.
• Delegates responsibility appropriately and supervises ancillary personnel to assure quality care and compliance with the care plan.
• Evaluates for and promotes a safe environment for the patient and complies with National Patient Safety Goals.
• Completes, maintains, and submits all required documentation that is timely, accurate, and relevant in compliance with agency policy.
• Meets all requirements for UAS‑NY assessor function: timely completion within regulatory standards, follow‑up assessments, and significant change assessments as needed.
• Reviews and confirms eligibility of a member in the PACE program based on Nursing Facility Level of Care (NFLOC) score obtained from the UAS‑NY assessment.
• Confirms eligibility of members with the members of the IDT.
• Performs care coordination as part of nursing visits to PACE members across all settings of care.
• Conducts collaborative care coordination to include internal (e.g., other IDT members) and/or external health care professionals (e.g., MD specialists, SNF staff, hospital staff) to assure care plan coordination and continuity of care.
• Only acts within the scope of the individual’s authority to practice.
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