Under the direct supervision of the Director of Nursing, the Triage Home Care Coordinator (LVN) is responsible for the execution and management of homecare services for program participants. This role ensures the seamless coordination of all contracted home services, durable medical equipment (DME), and skilled nursing home care.

In addition to home-based coordination, this position provides vital clinical support within the clinic, assisting with the triaging of participants to ensure timely medical intervention and efficient patient flow. As a clinical advocate within the High Desert PACE model, the coordinator actively participates in scheduled Interdisciplinary Team (IDT) and coordination meetings to ensure care plans are clinically appropriate and aligned with participant needs.

Responsibilities

• Perform physical evaluation, including vital signs and blood glucose monitoring
• Chart observations of participant’s condition during every visit and in patient health record within required timeframes. Report changes in condition to RN supervisor
• Complete medication reconciliation
• Promptly notify providers of changes in participant’s condition including any wounds, physical or behavioral changes
• Administer medication, screening tests, and immunizations as prescribed
• Perform basic wound care as prescribed
• Coordinate and communicate as needed with RN, occupational therapists, physical therapists, physicians, social workers, dieticians, and others on the participant’s care team.
• Provides vital clinical support within the clinic, assisting with the triaging of participants to ensure timely medical intervention and efficient patient flow.
• Report to RN supervisor when objective findings indicate that DME, home care assistance, nutritional services would improve participants’ quality of life and ability to live in the community
• Listen to the participant and communicate participant’s questions, concerns, and requests to the Home Care Supervisor promptly
• Educate participants and their families on home care strategies and procedures
• Participate in department and agency meetings as assigned
• Participate in all agencies’ quality assurance performance improvement program (QAPI) as assigned
• Maintain participant confidentiality per HIPPA/agency guidelines
• Document in accordance with PACE departmental guidelines and within the established time frame
• Act as a liaison between Homecare vendor and PACE related to participant’s needs

Education & Training

• Graduation from an accredited LVN school coupled with a current LVN license issued by the State of California Vocational Nursing and Psychiatric Technicians required.
• A minimum of one (1) year experience practicing as a Licensed Vocational Nurse.
• Current CPR/BLS certification also required.
• At least one year working with a frail or elderly population.
• Bilingual preferred.

Skills & Abilities

• Experience and knowledge regarding the physical, mental and social needs of the patients highly desirable.
• Skilled in communicating with participants, their families, and other staff members; ability to establish a helping, trusting relationship with participants.
• Ability to follow through with instructions and directions provided by supervisor, RN, QAPI coordinator, primary care physician, and/or medical director.
• Ability to utilize appropriate safety measures when providing care.
• Ability to work effectively and harmoniously as part of an interdisciplinary team, the elderly, providers of services, and peers.
• Must have experience with navigating on a computer.
• Well organized, dependable, flexible, and resourceful.
• Demonstrate effective communication skills and ability to work effectively with people in stressful situations. Communicate to supervisor of any problems that potentially affect efficiency/quality of care provided.

Working Conditions

The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Active valid driver’s license.
• Proof of active valid auto insurance.
• Operates medical equipment to assist with nursing care & provide appropriate treatment to participants.
• The work setting is in an Adult Day Health Center and primary care clinic environment with moderate noise levels and controlled temperatures.
• May be required to perform home visits to private homes of High Desert PACE participants
• Operates a motor vehicle for transport to home visits