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Community LPN

SUMMARY: The Community Licensed Practical Nurse (LPN) supplements the nursing care needs of participants as established in the Interdisciplinary Team (IDT) plan of care. The LPN assists the primary care providers in the collection of specific assessment data that is used by the IDT in the planning of care needs. The LPN performs acts, task or functions under the direction of the RN, physician, or nurse practitioner, and acts only within the scope of his/her authority to practice. SPECIFIC DUTIES AND FUNCTIONS: The LPN works under the direction of the RN or primary care providers in the collection of specific assessment data, upon the initial visit to PACE of SE Michigan and upon routine re-evaluations; this data is used by the Interdisciplinary Team to plan for and evaluate participant needs. The LPN works with the participant, the family and all members of the interdisciplinary team in implementing the participants’ plan of care. The LPN assists with data collection for routine as well as episodic visits to the clinic; the LPN communicates his/her findings to the medical provider or the team for evaluating or modifying the plan of care. The LPN prepares and administers medications as ordered by the physician he/she administers, in a safe, accurate, and timely manner. The LPN demonstrates knowledge of the medications he/she administers, including actions and side effects, and instructs the participant/family in safe administration of medications at home. The LPN signs, dates, and performs all charting/documentation of medications; the LPN reports and follows up on any medication errors in accordance with the policies and procedures of PACE; the LPN participates in the collection of information and maintains accurate records of participant functional status and care given. The LPN advocates to others on behalf of the participant and demonstrates accountability in resolving participant concerns or issues. The LPN understands, complies with and promotes the Participant Bill of Rights and assesses and works toward achieving high levels of participant satisfaction. KNOWLEDGE, SKILLS, AND ABILITIES: The LPN participates in annual, mandatory in-service training and screening, including but not limited to: infection control, TB testing, safety training, and BLS training. The LPN assumes responsibility for self-development through continuing education, utilizing resources, within the health care system or elsewhere. Must be a Licensed Practical Nurse with current Michigan licensure. The ability to establish and maintain interpersonal and interdisciplinary relationships. The LPN assists the RN with the implementation of nursing research studies through gathering of data. The LPN reviews current periodical literature relevant to the general practice of nursing well as information pertaining to the PACE model of care. Must have one (1) year of experience with frail or elderly population. Must meet a standardized set of competencies before working independently. Must be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact. WORKING CONDITIONS: Manual dexterity is required to complete tasks; walking, stooping, standing, reaching, bending and lifting of forty (40) pounds or more may be needed in the performance of duties. Working conditions are variable with exposure to communicable diseases, due to patient environment.

Nursing Assistant – Franklin Terrace Community Living - days

PACE Southeast Michigan Southfield, MI

SUMMARY: Under the management of the PACE SEMI’s Community Living Manager and the coordination of the Lead CLA, the Community Living Associate (CLA) provides supportive services to the participants (residents); including but not limited to the community setting, during transport and on appointments, or in the day health center while under the supervision of the manager, registered nurse, or lead CLA. The CLA’s responsibilities for each participant are specified in the CLA Care Plan. The following statements are intended to describe the essential elements, functions, and requirements of the position. The list should not be taken as an exhaustive list of all responsibilities, duties, and skills required of an individual assigned to this job. SPECIFIC DUTIES AND FUNCTIONS: The CLA plan of care is based on the initial and on-going assessments that are performed by the manager, assigned RNCM/clinical team, and lead CLA. The CLA assists in providing and/or maintaining optimal physical and emotional comforts to the participants (residents) living in the community setting while embracing the culture, mission, values, and the practicing Ten Principles at PACE SEMI. The CLA assists in creating a nurturing supportive environment while helping participants (residents) achieve maximum self-reliance and independence within the community living setting. The CLA performs the care or services that are outlined in the individual participant’s care plan; any care guidelines that are pertinent to the participant’s diagnosis are specified in the care plan. The CLA performs a variety of tasks and services for the participants (residents), including: Personal care up to and including 2-person assist 1:1 interaction in DHC and CL as outlined in the plan of care Assistance with activities Assistance with meal preparation / cooking/ feeding/other nutritional needs Assistance with toileting / managing incontinence Simple treatments Grocery shopping Laundry services Coordination of care with participant and the DHC based on care plan Engage with resident elevating health concerns and customer services issues or needs appropriately Homemaking services / chores/ housekeeping services/sanitizing equipment All other duties as required by manager and lead CLA, as assigned Rounds q2 hour after 7pm-7am. The CLA is responsible for accurate timely documentation as required by the community living setting; including but not limited to the care and/or services provided during participant (resident) encounter(s). The CLA keeps the manager, lead CLA, and clinical team informed of the participant’s progress. Immediately reports all customer service complaints, all deviations from set schedule and appointments to supervisor /manager or lead CLA. The CLA responds to emergency situations in accordance with established policies and procedures. Works only within established scope of practice. KNOWLEDGE, SKILLS AND ABILITIES: H.S. diploma or GED required Valid Michigan Driver's license Current CPR card required Certification is optional though preferred, but must have one (1) year experience with a frail or elderly population Experience must be in a long-term care, hospital, home care setting, or PACE setting Required completion of a basic nursing assistant training program. Must have received certificate of completion from a formal training program (Direct Care, Nurse Assistant, Medical Assistant, etc.) outside of PACE SEMI The CLA participates in annual, mandatory in-service training and screening, including but not limited to: infection control, TB testing, safety training, and BLS training The CLA must possess the ability to establish and maintain interpersonal and interdepartmental relationships The CLA shows respect for the physical, spiritual, and well-being of participants and co-workers The CLA must have the ability to problem solve and interpret instructions The CLA must be able to organize and maintain flexible scheduling to coordinate job responsibilities Ability to work sensitively with individuals of diverse ethnic and cultural backgrounds Ability to relate to those participants with dementia and/or developmental disabilities The CLA must be able to perform duties in an atmosphere of frequent interruption Must meet a standardized set of competencies (approval by CMS) before working independently CLA competency is monitored and maintained in a variety of ways: Initially, through a skills check-off performance evaluation of specific tasks upon hire and orientation to the program, and annually thereafter Job related competency in-services including a practicum demonstration and written assessment Mandatory in-service training Department staff meetings Must be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact. SUMMARY OF WORKING CONDITIONS: Working conditions are variable. With exposure to communicable diseases, due to participant environment. There is also potential for exposure to chemicals such as cleaning solutions and medications The CLA is supervised regularly in the community setting, by the manager and RNCM by direct or indirect supervision. At this time the participant’s satisfaction with the Care Plan and CLA is evaluated Driving is required within PACE SEMI catchment area The CLA must have reliable transportation available on a daily basis, a current valid driver’s license, must maintain an acceptable driving record, and provide proof of current automobile insurance The CLA must have the ability to transfer and assist with moving patients; frequent walking, bending, and lifting of forty (40) pounds or more may be needed in the performance of duties The CLA may be required to change participant assignments based on the changing acuity level, participant needs, and participant census.

Nursing Assistant - Village of Westland Community Living - days

PACE Southeast Michigan Westland, MI

SUMMARY: Under the management of the PACE SEMI’s Community Living Manager and the coordination of the Lead CLA, the Community Living Associate (CLA) provides supportive services to the participants (residents); including but not limited to the community setting, during transport and on appointments, or in the day health center while under the supervision of the manager, registered nurse, or lead CLA. The CLA’s responsibilities for each participant are specified in the CLA Care Plan. The following statements are intended to describe the essential elements, functions, and requirements of the position. The list should not be taken as an exhaustive list of all responsibilities, duties, and skills required of an individual assigned to this job. SPECIFIC DUTIES AND FUNCTIONS: The CLA plan of care is based on the initial and on-going assessments that are performed by the manager, assigned RNCM/clinical team, and lead CLA. The CLA assists in providing and/or maintaining optimal physical and emotional comforts to the participants (residents) living in the community setting while embracing the culture, mission, values, and the practicing Ten Principles at PACE SEMI. The CLA assists in creating a nurturing supportive environment while helping participants (residents) achieve maximum self-reliance and independence within the community living setting. The CLA performs the care or services that are outlined in the individual participant’s care plan; any care guidelines that are pertinent to the participant’s diagnosis are specified in the care plan. The CLA performs a variety of tasks and services for the participants (residents), including: Personal care up to and including 2-person assist 1:1 interaction in DHC and CL as outlined in the plan of care Assistance with activities Assistance with meal preparation / cooking/ feeding/other nutritional needs Assistance with toileting / managing incontinence Simple treatments Grocery shopping Laundry services Coordination of care with participant and the DHC based on care plan Engage with resident elevating health concerns and customer services issues or needs appropriately Homemaking services / chores/ housekeeping services/sanitizing equipment All other duties as required by manager and lead CLA, as assigned Rounds q2 hour after 7pm-7am. The CLA is responsible for accurate timely documentation as required by the community living setting; including but not limited to the care and/or services provided during participant (resident) encounter(s). The CLA keeps the manager, lead CLA, and clinical team informed of the participant’s progress. Immediately reports all customer service complaints, all deviations from set schedule and appointments to supervisor /manager or lead CLA. The CLA responds to emergency situations in accordance with established policies and procedures. Works only within established scope of practice. KNOWLEDGE, SKILLS AND ABILITIES: H.S. diploma or GED required Valid Michigan Driver's license Current CPR card required Certification is optional though preferred, but must have one (1) year experience with a frail or elderly population Experience must be in a long-term care, hospital, home care setting, or PACE setting Required completion of a basic nursing assistant training program. Must have received certificate of completion from a formal training program (Direct Care, Nurse Assistant, Medical Assistant, etc.) outside of PACE SEMI The CLA participates in annual, mandatory in-service training and screening, including but not limited to: infection control, TB testing, safety training, and BLS training The CLA must possess the ability to establish and maintain interpersonal and interdepartmental relationships The CLA shows respect for the physical, spiritual, and well-being of participants and co-workers The CLA must have the ability to problem solve and interpret instructions The CLA must be able to organize and maintain flexible scheduling to coordinate job responsibilities Ability to work sensitively with individuals of diverse ethnic and cultural backgrounds Ability to relate to those participants with dementia and/or developmental disabilities The CLA must be able to perform duties in an atmosphere of frequent interruption Must meet a standardized set of competencies (approval by CMS) before working independently CLA competency is monitored and maintained in a variety of ways: Initially, through a skills check-off performance evaluation of specific tasks upon hire and orientation to the program, and annually thereafter Job related competency in-services including a practicum demonstration and written assessment Mandatory in-service training Department staff meetings Must be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact. SUMMARY OF WORKING CONDITIONS: Working conditions are variable. With exposure to communicable diseases, due to participant environment. There is also potential for exposure to chemicals such as cleaning solutions and medications The CLA is supervised regularly in the community setting, by the manager and RNCM by direct or indirect supervision. At this time the participant’s satisfaction with the Care Plan and CLA is evaluated Driving is required within PACE SEMI catchment area The CLA must have reliable transportation available on a daily basis, a current valid driver’s license, must maintain an acceptable driving record, and provide proof of current automobile insurance The CLA must have the ability to transfer and assist with moving patients; frequent walking, bending, and lifting of forty (40) pounds or more may be needed in the performance of duties The CLA may be required to change participant assignments based on the changing acuity level, participant needs, and participant census.

Nurse Practitioner - Part Time - Westland

PACE Southeast Michigan Westland, MI

SUMMARY: The Nurse Practitioner (NP) is responsible for primary care to an assigned panel of participants at PACE SEMI. As such, they are responsible for participant acute and chronic care management under direction and supervision of the center Physician-In-Charge (PIC). SPECIFIC DUTIES AND FUNCTIONS: Chronic Disease Management Responsible for performing monthly quota of comprehensive annual and semi-annual assessments Chronic Care Management visits done every 3 months Changes in chronic disease or new diagnoses, and updating management and treatment plans accordingly Conferring with the Physician and other clinical team members with changes in participant status Pharmacy Prescribing including controlled substances, Schedule 3- Schedule 5 medications, that the supervising physician has delegated Specialty and diagnostic referrals with staff physician guidance Initiating appropriate diagnostic studies, such as laboratory, x-ray and other specialty procedures with physician approval/oversight Interdisciplinary Collaboration- Coordinates care with the IDT , PCT, UM, and other PACE services communicating participant changes to the interdisciplinary team Preventative Care Services Acute Care Management and Treatment Patient Education Documentation: Documents in the medical record in the “SOAP Format”, Completion of notes with full assessment preferably within 24 hours but no later than 72 hours, Facilitates Coding capture of Hierarchical Chronic Conditions Utilization Management - Contributes to Utilization Management Goals of Care: Facilitates Advanced Directives, Facilitates Goals of Care and End-of Life Discussions with participants and families: Facilitates Advanced Directives, Manages end-of-life with support of consulting hospice service. Location of Care: Clinic (mostly), Participants Home, Nursing Facility and Telemedicine After-Hours Call- May participate in after hours on-call medical assistance on a rotating basis via telephone triage or after-hours home visits to participants as needed. Participation in Monthly Education Conference SCOPE OF PRACTICE In accordance to Michigan law, an NP may practice independently within his/her scope of practice per professional license; specifically, a Nurse Practitioner may practice independent per RN licensing scope. However, outside of that scope, he/she must practice under the supervising physician’s scope of practice per his/her delegation. Supervision of the NP provided by several methods: Immediate, on-site supervision by the PACE SEMI physician; Telephone consultation with a PACE SEMI physician who is not on the premises PROFESSIONAL REQUIREMENTS Three (3) to five (5) years of progressively more responsible experience as an RN in a clinical setting with expertise substantiated in the area of geriatrics is preferred, through education, experience and credentials. Must have one (1) year of experience with a frail or elderly population. Maintain current Michigan NP License in good standing and fulfills CME requirements The nurse practitioner must comply with PACE guidelines for TB screenings, infection control, BLS and mandatory in-service requirements. The nurse practitioner acts as a role model for professional nursing practice among his/her peers. The nurse practitioner supports and contributes to the development of nursing students as well as students of other health-related disciplines. The ability to establish and maintain interpersonal and interdepartmental relationships. The ability to apply principles of teaching/learning theories in planning and implementing educational activities.

Nurse Practitioner

PACE Southeast Michigan Westland, MI

SUMMARY: The Nurse Practitioner (NP) is responsible for primary care to an assigned panel of participants at PACE SEMI. As such, they are responsible for participant acute and chronic care management under direction and supervision of the center Physician-In-Charge (PIC). SPECIFIC DUTIES AND FUNCTIONS: Chronic Disease Management Responsible for performing monthly quota of comprehensive annual and semi-annual assessments Chronic Care Management visits done every 3 months Changes in chronic disease or new diagnoses, and updating management and treatment plans accordingly Conferring with the Physician and other clinical team members with changes in participant status Pharmacy Prescribing including controlled substances, Schedule 3- Schedule 5 medications, that the supervising physician has delegated Specialty and diagnostic referrals with staff physician guidance Initiating appropriate diagnostic studies, such as laboratory, x-ray and other specialty procedures with physician approval/oversight Interdisciplinary Collaboration- Coordinates care with the IDT , PCT, UM, and other PACE services communicating participant changes to the interdisciplinary team Preventative Care Services Acute Care Management and Treatment Patient Education Documentation: Documents in the medical record in the “SOAP Format”, Completion of notes with full assessment preferably within 24 hours but no later than 72 hours, Facilitates Coding capture of Hierarchical Chronic Conditions Utilization Management - Contributes to Utilization Management Goals of Care: Facilitates Advanced Directives, Facilitates Goals of Care and End-of Life Discussions with participants and families: Facilitates Advanced Directives, Manages end-of-life with support of consulting hospice service. Location of Care: Clinic (mostly), Participants Home, Nursing Facility and Telemedicine After-Hours Call- May participate in after hours on-call medical assistance on a rotating basis via telephone triage or after-hours home visits to participants as needed. Participation in Monthly Education Conference SCOPE OF PRACTICE In accordance to Michigan law, an NP may practice independently within his/her scope of practice per professional license; specifically, a Nurse Practitioner may practice independent per RN licensing scope. However, outside of that scope, he/she must practice under the supervising physician’s scope of practice per his/her delegation. Supervision of the NP provided by several methods: Immediate, on-site supervision by the PACE SEMI physician; Telephone consultation with a PACE SEMI physician who is not on the premises PROFESSIONAL REQUIREMENTS Three (3) to five (5) years of progressively more responsible experience as an RN in a clinical setting with expertise substantiated in the area of geriatrics is preferred, through education, experience and credentials. Must have one (1) year of experience with a frail or elderly population. Maintain current Michigan NP License in good standing and fulfills CME requirements The nurse practitioner must comply with PACE guidelines for TB screenings, infection control, BLS and mandatory in-service requirements. The nurse practitioner acts as a role model for professional nursing practice among his/her peers. The nurse practitioner supports and contributes to the development of nursing students as well as students of other health-related disciplines. The ability to establish and maintain interpersonal and interdepartmental relationships. The ability to apply principles of teaching/learning theories in planning and implementing educational activities.

Nurse Practitioner

PACE Southeast Michigan Westland, MI

SUMMARY: The Nurse Practitioner (NP) is responsible for primary care to an assigned panel of participants at PACE SEMI. As such, they are responsible for participant acute and chronic care management under direction and supervision of the center Physician-In-Charge (PIC). SPECIFIC DUTIES AND FUNCTIONS: Chronic Disease Management Responsible for performing monthly quota of comprehensive annual and semi-annual assessments Chronic Care Management visits done every 3 months Changes in chronic disease or new diagnoses, and updating management and treatment plans accordingly Conferring with the Physician and other clinical team members with changes in participant status Pharmacy Prescribing including controlled substances, Schedule 3- Schedule 5 medications, that the supervising physician has delegated Specialty and diagnostic referrals with staff physician guidance Initiating appropriate diagnostic studies, such as laboratory, x-ray and other specialty procedures with physician approval/oversight Interdisciplinary Collaboration- Coordinates care with the IDT , PCT, UM, and other PACE services communicating participant changes to the interdisciplinary team Preventative Care Services Acute Care Management and Treatment Patient Education Documentation: Documents in the medical record in the “SOAP Format”, Completion of notes with full assessment preferably within 24 hours but no later than 72 hours, Facilitates Coding capture of Hierarchical Chronic Conditions Utilization Management - Contributes to Utilization Management Goals of Care: Facilitates Advanced Directives, Facilitates Goals of Care and End-of Life Discussions with participants and families: Facilitates Advanced Directives, Manages end-of-life with support of consulting hospice service. Location of Care: Clinic (mostly), Participants Home, Nursing Facility and Telemedicine After-Hours Call- May participate in after hours on-call medical assistance on a rotating basis via telephone triage or after-hours home visits to participants as needed. Participation in Monthly Education Conference SCOPE OF PRACTICE In accordance to Michigan law, an NP may practice independently within his/her scope of practice per professional license; specifically, a Nurse Practitioner may practice independent per RN licensing scope. However, outside of that scope, he/she must practice under the supervising physician’s scope of practice per his/her delegation. Supervision of the NP provided by several methods: Immediate, on-site supervision by the PACE SEMI physician; Telephone consultation with a PACE SEMI physician who is not on the premises PROFESSIONAL REQUIREMENTS Three (3) to five (5) years of progressively more responsible experience as an RN in a clinical setting with expertise substantiated in the area of geriatrics is preferred, through education, experience and credentials. Must have one (1) year of experience with a frail or elderly population. Maintain current Michigan NP License in good standing and fulfills CME requirements The nurse practitioner must comply with PACE guidelines for TB screenings, infection control, BLS and mandatory in-service requirements. The nurse practitioner acts as a role model for professional nursing practice among his/her peers. The nurse practitioner supports and contributes to the development of nursing students as well as students of other health-related disciplines. The ability to establish and maintain interpersonal and interdepartmental relationships. The ability to apply principles of teaching/learning theories in planning and implementing educational activities.

Registered Nurse Case Manager

PACE Southeast Michigan Detroit, MI

SUMMARY: 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: The RNCM assesses participants’ needs and plans for appropriate nursing care upon the Initial Intake Assessment as well as upon routine Re-Evaluation Assessments. The RNCM works and collaborates with the participant and the family, as well as all members of the multidisciplinary Team in developing the participant’s plan of care. The RNCM maximizes the participant’s functional capacity by encouraging autonomy in all aspects of care. The RNCM teaches, supervises and counsels the participant, or caregiver regarding nursing care needs and other related problems. The RN utilizes adult learning principles when planning for and implementing educational information to the participants, caregivers or family members. The RNCM initiates preventative and rehabilitative procedures or programs as appropriate for the participants’ care and safety. The RNCM administers medications and treatments, as ordered by the physician/NP, and monitors the participant’s response. The RN notifies the appropriate medical personnel of changes in the participant’s status. The RNCM demonstrates knowledge of the medications he/she administers and instructs the participant/family in safe administration of medication in the home. Assesses for and encourages compliance with medication regimen. The RNCM recognizes and understands the significance of abnormal test results and utilizes critical thinking skills when gathering participant data, planning for, and implementing care. The RNCM provides safe total patient care to participants with complex health problems with a focus on the individual participant and the family. The RNCM maintains all standards of nursing practice and follows hospital policies/procedures for care delivery and medication administration. The RNCM leads and monitors licensed and other professional and non-professional staff in the delivery of nursing care to the participant in the home. The RN is responsible for monthly supervision and subsequent documentation of home health aide services provided in the participant’s home. The RNCM evaluates participant outcomes and or progress toward achieving the objectives/goals of the care plan and communicates this information among other members of the Multidisciplinary Team. The RNCM collaborates with the Interdisciplinary Team to revise the plan of care based on changes in the participants’ physical or psychosocial status, and initiates actions that are consistent with the changes in status. The RNCN participates 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. The RNCM maintains accurate and timely records of participant’s functional /health status, progress toward care plan outcomes, revisions to care plans, care given, etc. All charting and documentation is performed in accordance with CSI policies/procedures. The RNCM participates in the collection and documentation of Data PACE information. The RNCM advocates to others on behalf of the participant, and demonstrates accountability in resolving participant concerns or issues. The RNCM understands, complies with and promotes the Participant Bill of Rights and assesses and works toward achieving high levels of participant satisfaction. The RNCM may provide after hours on-call medical assistance on a rotating basis, via phone triage or after hours home visits to participants as needed. Schedule requires a rotating on call shift. KNOWLEDGE, SKILLS AND ABILITIES: Must be a Registered Nurse with current Michigan licensure, BSN preferred. The RNCM participates in annual, mandatory in-service training and screening, including but not limited to: infection control, TB testing, safety training, and BLS training. The RNCM assumes responsibility for self-development through continuing education, utilizing resources within the health care system or elsewhere; the RN promotes professional behavior and growth by serving as a role model within the health team. The RNCM must possess a current State of Michigan driver’s license and maintain an acceptable driving record. The RNCM has the ability to establish and maintain interpersonal and interdepartmental relationships. The RNCM has the ability to apply principles of adult learning in planning and implementing educational activities. The RNCM has the ability to lead and direct other licensed and non-professional nursing staff in the delivery of care. The RNCM participates in and/or facilitates Quality Assurance projects resulting from data results. The RNCM assists with the implementation of nursing research studies. The RNCM reviews current periodical literature relevant to the general practice of nursing as well as information pertaining to the PACE model of care. The RNCM ensures adherence to departmental and external standards in the provision of quality focused care by attendance at professional meetings/committees and review of national standards of practice. Must meet a standardized set of competencies (approved by CMS) before working independently. Must have one (1) year of experience with a frail or elderly population. WORKING CONDITIONS: Works in the participant’s home which is an uncontrolled environment. May be exposed to potentially infectious materials, blood-borne disease pathogens, and hazardous waste. Must be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact Driving is required within PACE SEMI catchment area, with possible exposure to extreme temperatures, including heat and cold. Must have reliable transportation available on a daily basis. Frequent walking, bending, lifting of forty (40) pounds or more may be needed in the performance of duties.

Registered Nurse Case Manager - Detroit

PACE Southeast Michigan Detroit, MI

SUMMARY: 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: The RNCM assesses participants’ needs and plans for appropriate nursing care upon the Initial Intake Assessment as well as upon routine Re-Evaluation Assessments. The RNCM works and collaborates with the participant and the family, as well as all members of the multidisciplinary Team in developing the participant’s plan of care. The RNCM maximizes the participant’s functional capacity by encouraging autonomy in all aspects of care. The RNCM teaches, supervises and counsels the participant, or caregiver regarding nursing care needs and other related problems. The RN utilizes adult learning principles when planning for and implementing educational information to the participants, caregivers or family members. The RNCM initiates preventative and rehabilitative procedures or programs as appropriate for the participants’ care and safety. The RNCM administers medications and treatments, as ordered by the physician/NP, and monitors the participant’s response. The RN notifies the appropriate medical personnel of changes in the participant’s status. The RNCM demonstrates knowledge of the medications he/she administers and instructs the participant/family in safe administration of medication in the home. Assesses for and encourages compliance with medication regimen. The RNCM recognizes and understands the significance of abnormal test results and utilizes critical thinking skills when gathering participant data, planning for, and implementing care. The RNCM provides safe total patient care to participants with complex health problems with a focus on the individual participant and the family. The RNCM maintains all standards of nursing practice and follows hospital policies/procedures for care delivery and medication administration. The RNCM leads and monitors licensed and other professional and non-professional staff in the delivery of nursing care to the participant in the home. The RN is responsible for monthly supervision and subsequent documentation of home health aide services provided in the participant’s home. The RNCM evaluates participant outcomes and or progress toward achieving the objectives/goals of the care plan and communicates this information among other members of the Multidisciplinary Team. The RNCM collaborates with the Interdisciplinary Team to revise the plan of care based on changes in the participants’ physical or psychosocial status, and initiates actions that are consistent with the changes in status. The RNCM participates 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. The RNCM maintains accurate and timely records of participant’s functional /health status, progress toward care plan outcomes, revisions to care plans, care given, etc. All charting and documentation is performed in accordance with CSI policies/procedures. The RNCM participates in the collection and documentation of Data PACE information. The RNCM advocates to others on behalf of the participant, and demonstrates accountability in resolving participant concerns or issues. The RNCM understands, complies with and promotes the Participant Bill of Rights and assesses and works toward achieving high levels of participant satisfaction. The RNCM may provide after hours on-call medical assistance on a rotating basis, via phone triage or after hours home visits to participants as needed. Schedule requires a rotating on call shift. KNOWLEDGE, SKILLS AND ABILITIES: Must be a Registered Nurse with current Michigan licensure, BSN preferred. The RNCM participates in annual, mandatory in-service training and screening, including but not limited to: infection control, TB testing, safety training, and BLS training. The RNCM assumes responsibility for self-development through continuing education, utilizing resources within the health care system or elsewhere; the RN promotes professional behavior and growth by serving as a role model within the health team. The RNCM must possess a current State of Michigan driver’s license and maintain an acceptable driving record. The RNCM has the ability to establish and maintain interpersonal and interdepartmental relationships. The RNCM has the ability to apply principles of adult learning in planning and implementing educational activities. The RNCM has the ability to lead and direct other licensed and non-professional nursing staff in the delivery of care. The RNCM participates in and/or facilitates Quality Assurance projects resulting from data results. The RNCM assists with the implementation of nursing research studies. The RNCM reviews current periodical literature relevant to the general practice of nursing as well as information pertaining to the PACE model of care. The RNCM ensures adherence to departmental and external standards in the provision of quality focused care by attendance at professional meetings/committees and review of national standards of practice. Must meet a standardized set of competencies (approved by CMS) before working independently. Must have one (1) year of experience with a frail or elderly population. WORKING CONDITIONS: Works in the participant’s home which is an uncontrolled environment. May be exposed to potentially infectious materials, blood-borne disease pathogens, and hazardous waste. Must be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact Driving is required within PACE SEMI catchment area, with possible exposure to extreme temperatures, including heat and cold. Must have reliable transportation available on a daily basis. Frequent walking, bending, lifting of forty (40) pounds or more may be needed in the performance of duties.

Nurse Practitioner

PACE Southeast Michigan Southfield, MI

SUMMARY: The Nurse Practitioner (NP) is responsible for primary care to an assigned panel of participants at PACE SEMI. As such, they are responsible for participant acute and chronic care management under direction and supervision of the center Physician-In-Charge (PIC). SPECIFIC DUTIES AND FUNCTIONS: Chronic Disease Management Responsible for performing monthly quota of comprehensive annual and semi-annual assessments Chronic Care Management visits done every 3 months Changes in chronic disease or new diagnoses, and updating management and treatment plans accordingly Conferring with the Physician and other clinical team members with changes in participant status Pharmacy Prescribing including controlled substances, Schedule 3- Schedule 5 medications, that the supervising physician has delegated Specialty and diagnostic referrals with staff physician guidance Initiating appropriate diagnostic studies, such as laboratory, x-ray and other specialty procedures with physician approval/oversight Interdisciplinary Collaboration- Coordinates care with the IDT , PCT, UM, and other PACE services communicating participant changes to the interdisciplinary team Preventative Care Services Acute Care Management and Treatment Patient Education Documentation: Documents in the medical record in the “SOAP Format”, Completion of notes with full assessment preferably within 24 hours but no later than 72 hours, Facilitates Coding capture of Hierarchical Chronic Conditions Utilization Management - Contributes to Utilization Management Goals of Care: Facilitates Advanced Directives, Facilitates Goals of Care and End-of Life Discussions with participants and families: Facilitates Advanced Directives, Manages end-of-life with support of consulting hospice service. Location of Care: Clinic (mostly), Participants Home, Nursing Facility and Telemedicine After-Hours Call- May participate in after hours on-call medical assistance on a rotating basis via telephone triage or after-hours home visits to participants as needed. Participation in Monthly Education Conference SCOPE OF PRACTICE In accordance to Michigan law, an NP may practice independently within his/her scope of practice per professional license; specifically, a Nurse Practitioner may practice independent per RN licensing scope. However, outside of that scope, he/she must practice under the supervising physician’s scope of practice per his/her delegation. Supervision of the NP provided by several methods: Immediate, on-site supervision by the PACE SEMI physician; Telephone consultation with a PACE SEMI physician who is not on the premises PROFESSIONAL REQUIREMENTS Three (3) to five (5) years of progressively more responsible experience as an RN in a clinical setting with expertise substantiated in the area of geriatrics is preferred, through education, experience and credentials. Must have one (1) year of experience with a frail or elderly population. Maintain current Michigan NP License in good standing and fulfills CME requirements The nurse practitioner must comply with PACE guidelines for TB screenings, infection control, BLS and mandatory in-service requirements. The nurse practitioner acts as a role model for professional nursing practice among his/her peers. The nurse practitioner supports and contributes to the development of nursing students as well as students of other health-related disciplines. The ability to establish and maintain interpersonal and interdepartmental relationships. The ability to apply principles of teaching/learning theories in planning and implementing educational activities.

Nurse practitioner

PACE Southeast Michigan Dearborn, MI

SUMMARY: The Nurse Practitioner (NP) is responsible for primary care to an assigned panel of participants at PACE SEMI. As such, they are responsible for participant acute and chronic care management under direction and supervision of the center Physician-In-Charge (PIC). SPECIFIC DUTIES AND FUNCTIONS: Chronic Disease Management Responsible for performing monthly quota of comprehensive annual and semi-annual assessments Chronic Care Management visits done every 3 months Changes in chronic disease or new diagnoses, and updating management and treatment plans accordingly Conferring with the Physician and other clinical team members with changes in participant status Pharmacy Prescribing including controlled substances, Schedule 3- Schedule 5 medications, that the supervising physician has delegated Specialty and diagnostic referrals with staff physician guidance Initiating appropriate diagnostic studies, such as laboratory, x-ray and other specialty procedures with physician approval/oversight Interdisciplinary Collaboration- Coordinates care with the IDT , PCT, UM, and other PACE services communicating participant changes to the interdisciplinary team Preventative Care Services Acute Care Management and Treatment Patient Education Documentation: Documents in the medical record in the “SOAP Format”, Completion of notes with full assessment preferably within 24 hours but no later than 72 hours, Facilitates Coding capture of Hierarchical Chronic Conditions Utilization Management - Contributes to Utilization Management Goals of Care: Facilitates Advanced Directives, Facilitates Goals of Care and End-of Life Discussions with participants and families: Facilitates Advanced Directives, Manages end-of-life with support of consulting hospice service. Location of Care: Clinic (mostly), Participants Home, Nursing Facility and Telemedicine After-Hours Call- May participate in after hours on-call medical assistance on a rotating basis via telephone triage or after-hours home visits to participants as needed. Participation in Monthly Education Conference SCOPE OF PRACTICE In accordance to Michigan law, an NP may practice independently within his/her scope of practice per professional license; specifically, a Nurse Practitioner may practice independent per RN licensing scope. However, outside of that scope, he/she must practice under the supervising physician’s scope of practice per his/her delegation. Supervision of the NP provided by several methods: Immediate, on-site supervision by the PACE SEMI physician; Telephone consultation with a PACE SEMI physician who is not on the premises PROFESSIONAL REQUIREMENTS Three (3) to five (5) years of progressively more responsible experience as an RN in a clinical setting with expertise substantiated in the area of geriatrics is preferred, through education, experience and credentials. Must have one (1) year of experience with a frail or elderly population. Maintain current Michigan NP License in good standing and fulfills CME requirements The nurse practitioner must comply with PACE guidelines for TB screenings, infection control, BLS and mandatory in-service requirements. The nurse practitioner acts as a role model for professional nursing practice among his/her peers. The nurse practitioner supports and contributes to the development of nursing students as well as students of other health-related disciplines. The ability to establish and maintain interpersonal and interdepartmental relationships. The ability to apply principles of teaching/learning theories in planning and implementing educational activities.

Nursing Assistant

PACE Southeast Michigan Southfield, MI

SUMMARY: The P articipant Care Associate (PCA), provides supportive services to the participant; including but not limited to in the home or community setting, during transport and on appointments, or and in the day health center. The PCA’s responsibilities for each participant are specified in the PCA/CNA Care Plan. The following statements are intended to describe the essential elements, functions, and requirements of the position. The list should not be taken as an exhaustive list of all responsibilities, duties, and skills required of an individual assigned to this job. SPECIFIC DUTIES AND FUNCTIONS: The PCA plan of care is based on the initial and on-going assessments that are performed by a home care RNCM. The PCA assists in providing and/or maintaining optimal physical and emotional comforts to frail elders, in the participant’s home, community setting, day health center, and dementia unit, and during transport and on appointments. The PCA assists participants and their families toward achieving maximum self-reliance and independence within their environment, day health center, and dementia unit. The PCA performs the care or services that are outlined in the individual participant’s Care Plan; any Care Guidelines that are pertinent to the participant’s diagnosis are specified in the Care Plan. The PCA performs a variety of tasks and services for the participant, including: Personal Care, Assistance with activities, Assistance with meal preparation/feeding, Assistance with toileting/managing incontinence, simple treatments, shopping, medication reminder, laundry services, extending hours care, homemaking services/chores, transportation and off site appointment support. The PCA is responsible for accurate timely documentation as required by the service area they are supporting; including but not limited to the care and/or services provided on every visit and or encounter, transport and appointment, on the PCA/CNA progress note; the PCA keeps the RNCM and or clinic nurse informed of the participant’s progress. Immediately reports all customer service complaints, all deviations from set schedule and appointments to supervisor / manager. The PCA responds to emergency situations in accordance with established policies and procedures. Works only within established scope of practice. KNOWLEDGE, SKILLS AND ABILITIES: H.S. diploma or GED required Valid Michigan Driver's license Current CPR card required Certification is optional though preferred, but must have one (1) year experience with a frail or elderly population Experience must be in a long-term care, hospital, or home care setting Must have received certificate of completion from a formal training program (Direct Care, Nurse Assistant, Medical Assistant, Patient Care Technician, etc.) outside of PACE SEMI The PCA participates in annual, mandatory in-service training and screening, including but not limited to: infection control, TB testing, safety training, and BLS training The PCA must possess the ability to establish and maintain interpersonal and interdepartmental relationships The PCA shows respect for the physical, spiritual, and well-being of participants and co-workers The PCA must have the ability to problem solve and interpret instructions The PCA must be able to organize and maintain flexible scheduling to coordinate job responsibilities Ability to work sensitively with individuals of diverse ethnic and cultural backgrounds Ability to relate to those participants with dementia and/or developmental disabilities The PCA must be able to perform duties in an atmosphere of frequent interruption Must meet a standardized set of competencies (approval by CMS) before working independently PCA competency is monitored and maintained in a variety of ways: Initially, through a skills check-off performance evaluation of specific tasks upon hire and orientation to the program, and annually thereafter Job related competency in-services including a practicum demonstration and written assessment Mandatory in-service training Department staff meetings Must be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact. WORKING CONDITIONS:

Nurse Practitioner

PACE Southeast Michigan Westland, MI

SUMMARY: The Nurse Practitioner (NP) is responsible for primary care to an assigned panel of participants at PACE SEMI. As such, they are responsible for participant acute and chronic care management under direction and supervision of the center Physician-In-Charge (PIC). SPECIFIC DUTIES AND FUNCTIONS: Chronic Disease Management Responsible for performing monthly quota of comprehensive annual and semi-annual assessments Chronic Care Management visits done every 3 months Changes in chronic disease or new diagnoses, and updating management and treatment plans accordingly Conferring with the Physician and other clinical team members with changes in participant status Pharmacy Prescribing including controlled substances, Schedule 3- Schedule 5 medications, that the supervising physician has delegated Specialty and diagnostic referrals with staff physician guidance Initiating appropriate diagnostic studies, such as laboratory, x-ray and other specialty procedures with physician approval/oversight Interdisciplinary Collaboration- Coordinates care with the IDT , PCT, UM, and other PACE services communicating participant changes to the interdisciplinary team Preventative Care Services Acute Care Management and Treatment Patient Education Documentation: Documents in the medical record in the “SOAP Format”, Completion of notes with full assessment preferably within 24 hours but no later than 72 hours, Facilitates Coding capture of Hierarchical Chronic Conditions Utilization Management - Contributes to Utilization Management Goals of Care: Facilitates Advanced Directives, Facilitates Goals of Care and End-of Life Discussions with participants and families: Facilitates Advanced Directives, Manages end-of-life with support of consulting hospice service. Location of Care: Clinic (mostly), Participants Home, Nursing Facility and Telemedicine After-Hours Call- May participate in after hours on-call medical assistance on a rotating basis via telephone triage or after-hours home visits to participants as needed. Participation in Monthly Education Conference SCOPE OF PRACTICE In accordance to Michigan law, an NP may practice independently within his/her scope of practice per professional license; specifically, a Nurse Practitioner may practice independent per RN licensing scope. However, outside of that scope, he/she must practice under the supervising physician’s scope of practice per his/her delegation. Supervision of the NP provided by several methods: Immediate, on-site supervision by the PACE SEMI physician; Telephone consultation with a PACE SEMI physician who is not on the premises PROFESSIONAL REQUIREMENTS Three (3) to five (5) years of progressively more responsible experience as an RN in a clinical setting with expertise substantiated in the area of geriatrics is preferred, through education, experience and credentials. Must have one (1) year of experience with a frail or elderly population. Maintain current Michigan NP License in good standing and fulfills CME requirements The nurse practitioner must comply with PACE guidelines for TB screenings, infection control, BLS and mandatory in-service requirements. The nurse practitioner acts as a role model for professional nursing practice among his/her peers. The nurse practitioner supports and contributes to the development of nursing students as well as students of other health-related disciplines. The ability to establish and maintain interpersonal and interdepartmental relationships. The ability to apply principles of teaching/learning theories in planning and implementing educational activities.