Incumbent contributes to the assessment, plan, implementation, and evaluation of participants, documenting care in accordance with policies and standards, utilizing the framework for professional nursing practice and development. Position provides and contributes to the evaluation of care appropriate to the participant under the supervision of a Registered Nurse. Functions as a key member of the interdisciplinary team by supporting complex participant care coordination, early identification of clinical concerns, chronic disease management, and implementation of individualized care plans designed to maintain participants safely in the community while reducing avoidable emergency room visits and hospitalization. This is a full-time position, Monday- Friday 8-4 position; no nights, weekends or holidays!

Responsibilities:

• Maintains and manages an assigned participant caseload in collaboration with the Registered Nurse and interdisciplinary team.
• Monitors assigned participants for changes in condition, hospitalizations, ER visits, falls, wounds, medication concerns, or psychosocial changes and promptly communicates findings to the RN, provider, and appropriate IDT members.
• Coordinates scheduled nursing visits and communicates participant care needs, changes, and follow-up requirements to the care team.
• Supports urgent care and early intervention initiatives aimed at reducing unnecessary ER utilization and preventable hospital admissions.
• Participates in monitoring and follow-up of acute participant conditions, including post-ER and post-hospitalization care coordination and assist in identifying participants appropriate for urgent home-based interventions and communicates changes in condition promptly to the care team.
• Reinforces participant and caregiver education regarding appropriate use of on-call, urgent care resources, and when to contact Element Care prior to seeking emergency services.
• · Participates in during work visits to assigned patients in home care environment.
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  • Contributes to the assessment of the participant and reviews participant history. Reviews available information obtained by other IDT members and diagnostics and laboratory data and reports abnormal results to the physician(s) and other appropriate caregivers. Contributes to the assessment and reassessments according to participant need.
  • Follows and contributes to individualized plans of care based on participant needs, assessment findings, participant/family input, and the medical plan of care. Reviews and updates care plans in collaboration with the interdisciplinary team to reflect changing participant needs.
  • Implements the plan of care through direct participant care, coordination, delegation, and supervision of healthcare team activities. Provides care based on physician orders and the nursing plan of care while promoting continuity of care through accurate and timely communication.
  • Administers prescribed medications and provides basic patient care or treatments.
  • Evaluates participant and family response to care and teaching, contributing to revisions of the plan of care as needed. Assists in evaluating participant progress toward goals and expected outcomes in collaboration with the healthcare team..
  • Documents assessment, planning, implementation and evaluation in the participant record. [ML1]
  • Ability to pass a fit test. Position requires mask where seal is critical. Incumbent is required to not have facial hair that interferes with a tight seal of the respirator
  • Frequent local travel.
  • Performs other duties as assigned.

Qualifications:

• • Licensed Practical Nurse currently licensed in the Commonwealth of MA.
  • Minimum of two (2) years experience with the geriatric population.
  • Proficient in the use of Microsoft Office tools.
  • Ability to travel locally on a frequent basis in a personal vehicle.
  • Ability to be able to quickly recognize situations/problems before they become acute, and to be able to implement effective solutions and understand consequences.
    Covid vaccinated preferred.

Benefits:

• Health insurance
• Dental insurance
• Vision insurance
• Paid time off
• Retirement plan
• Supplemental benefits

EEO Statement

Element Care is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, national origin, sexual orientation, protected veteran status, or on the basis of disability.

Element Care is committed to valuing diversity and contributing to an inclusive working environment.