Under the supervision of the Director, Clinic and Home Care Services, the Home Care Coordinator provides a complete and thorough assessment of the home environment and the functional capabilities of each participant in the program. From this assessment and in collaboration with members of the Interdisciplinary Team, the Home Care Coordinator must make recommendations for home services. This position is responsible for establishing the services required and the time frames for the services. The Home Care Coordinator must be knowledgeable of the individual participant’s needs.
Assessment and Care Coordination: Completes initial assessment of the home environment and the functional capabilities of each participant, including, but not limited to: personal care and hygiene needs, medication administration abilities, cognitive abilities, participant and caregiver preferences, availability of family support, medical and psychosocial status, and any language barriers.
As a member of the Interdisciplinary Team, collaborates with the members (esp. Nursing and Rehabilitation) to determine the home care services needed by the participant, such as: personal care, medication administration, and chore services (cleaning, laundry, shopping).
Attends Interdisciplinary Team Care Planning sessions and provides input into the Care Plan.
Provides annual reassessments in the home per regulatory requirements.
In collaboration with the Home Care Services Manager, coordinates the implementation of home care services including, nursing, personal care, rehabilitation, supplies, and durable medical equipment.
Completes authorizations for necessary services authorized by the team.
Orients in-house and contracted staff to the participants being served and with his/her needs.
Evaluates the effectiveness of home care provided by both in-house and contracted staff by making periodic home visits.
Provides semi-annual home reassessments when home services are being provided.
Reassesses the home environment when a significant change in condition occurs that impacts the care requirements of the participant.
Communication: Counsels and educates participants and caregivers/family members towards self-help and recognition and resolution of medical, emotional, and environmental health problems.
Regularly informs the IDT of the medical, functional, and psychosocial condition of each participant.
Remains alert to pertinent input from other team members, participants, and caregivers.
Documents care provided in a timely manner, according to accepted professional standards and the organization’s medical records policies.
Documents changes in a participant’s condition in the medical record according to policy and procedure.
Nursing: Provides skilled nursing care and prescribed treatments, and demonstrates nursing care to participants and families in the participant’s home or in the clinic.
Demonstrates nursing care in compliance with accepted professional standards and the organization’s policies.
Rotates on-call duties with other nursing staff, to troubleshoot, advise, teach and coordinate participant care, including emergency services
Others duties as assigned.
TRAINING: On an annual basis employee will have completed training including:
the need of the clients in the center’s targeted population,
body mechanics/transfer techniques,
voluntary reporting requirements involving abuse, neglect and exploitation,
positive approach methods to manage behavior,
and a minimum of eight (8) hours targeted at enhancing the quality of care given and the employees job performance.
OPERATING PRINCIPLES.... Employees of Lutheran SeniorLife are expected to demonstrate the following through everyday performance of their job responsibilities:
Acknowledge the value of the contribution of each individual,
Demonstrate fairness and equity in all interactions,
Live with integrity, and be honest at all times,
Demonstrate excellence in service.
Performs other duties and responsibilities as assigned.
A registered nurse must be a graduate of a school of professional nursing. BSN Preferred.
2 years nursing experience, preferably in home care; Minimum of one (1) years’ experience working with a frail or elderly population.
Working knowledge of the interdisciplinary model of community care management.
Experience working with cognitively impaired seniors is important.
Must be able to relate well to seniors and their families to deal with sensitive issues and facilitate problem solving.
Must be flexible and able to change easily.
Working knowledge of computers, Microsoft Word and Excel required.