Nurse Practitioners provide primary medical management to PACE participants in collaboration with PACE physician(s). They conduct initial and semi-annual assessments, perform additional physical assessments as clinically indicated, and develop, implement, and monitor individualized plans of care. Nurse Practitioners evaluate participants’ physical and psychosocial complaints and provide appropriate medical treatment. They educate participants and their families, as needed, regarding self-care practices and specific medical conditions. Nurse Practitioners function as active members of the interdisciplinary team, contributing to comprehensive care planning and coordination. They provide daily clinical oversight of the PACE Clinic and perform medical rounds in PACE-contracted nursing facilities. Nurse Practitioners regularly communicate participants’ medical conditions to the interdisciplinary team and remain attentive to relevant input from team members, participants, and caregivers. All care is documented in the participant’s medical record in accordance with organizational documentation policies and regulatory requirements.

Qualifications and Requirements

Education, Training, and Certifications:

Graduate of an accredited school of nursing
Current Registered Nurse (RN) license
Advanced Practice Nurse (APN) license issued by the California Board of Nursing
Certification as a Nurse Practitioner with prescriptive authority
Current driver’s license, proof of insurance, and reliable means of transportation

Experience:

Minimum of two (2) years of experience working with the frail or elderly population

Duties and Responsibilities:

Perform initial, semi-annual, and unscheduled participant assessments.
Conduct additional physical assessments as needed and develop and implement appropriate treatment plans.
Provide primary medical coverage in collaboration with PACE physicians.
Function as a member of the interdisciplinary team by maintaining regular attendance and active participation in team meetings; communicating changes in participant condition; collaborating on care planning decisions; and coordinating 24-hour care delivery.
Integrate primary care treatment plans into the overall plan of care developed by the interdisciplinary team.
Collaborate with team members to address emergent and acute participant needs.
Participate in hospital and skilled nursing facility discharge planning, including return-to-home planning or short- or long-term placement.
Evaluate and treat participants during episodes of acute illness.
Manage chronic illnesses and conditions in collaboration with physician(s).
Manage the care of participants residing in nursing facilities, making regular visits as dictated by K-Day PACE standards and participant needs, and communicating with nursing facility staff as necessary.
Provide preventive healthcare services, including immunizations, screenings, and monitoring of relevant health indicators, in accordance with K-Day PACE clinical protocols.
Prescribe medications, therapies, and other treatments prudently and appropriately.
Refer participants to medical specialists in consultation with a physician.
Conduct hospital and home visits as required.
Participate in night and weekend on-call rotation.
Collaborate with the Medical Director and Clinic Supervisor to develop and implement clinical policies, procedures, and standards of care.
At the direction of the Medical Director, review medical outcomes, utilization data, and statistical reports, including the appropriateness of hospitalizations and specialist referrals. When issues are identified, collaborate with leadership and the interdisciplinary team to implement best practices and operational improvements to reduce unnecessary hospitalizations and improve participant outcomes.
Participate in assigned workgroups or committees (e.g., infection control, utilization review).
Assist in developing standards of care; conduct ongoing monitoring and evaluation of clinical practice and service delivery; and provide guidance and training to staff on medical and quality assurance matters.
Advise the Medical Director and physician(s) on methods to improve accountability of services to participants and referral sources.
Keep the Medical Director informed of staffing and material resource needs as the program grows.
Serve as a clinical resource during participant intake, daily center operations, and patient safety initiatives.
Provide clinical education and support to staff.
Maintain responsibility for professional development, including maintaining certifications, professional affiliations, and staying current with nursing best practices, particularly in geriatrics.
Participate in staff meetings, monthly in-service training, and peer review activities with the Medical Group.
Promote and champion continuous quality improvement initiatives.
Proactively educate staff regarding policies and procedures when non-compliance is identified.
Anticipate potential problems and take action to prevent escalation.
Comply with all organizational policies, procedures, and Occupational Safety and Health Administration (OSHA) regulations.
Protect privacy and maintain confidentiality of all organizational, employee, participant, and family information.
Adhere to standard precautions and established infection control protocols.
Participate in and support Quality Improvement initiatives.
Perform other duties as assigned or requested.

K-Day PACE

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