The Home Care Nurse (RN) provides all nursing functions according to Massachusetts Law and HHSI policy and procedure and is responsible for medical case management of home-based participants, providing home health services to geriatric participants of the Elder Service Plan (ESP) while building a trusting relationship with the participants.

The Elder Service Plan is a Program for All Inclusive Care for the Elderly (PACE) which provides a personalized healthcare program guided by a care plan developed and customized for our participants needs.

Job Duties - Home Care Nurse (RN):

• Performs routine clinical nursing duties, including history taking, vital signs, administration of medications, dressing changes and other nursing procedures under the verbal or written order of a provider as prescribed by law, written clinical policies and within the limits of his/her own license and training.

• Responsible for Case Managing home based ESP participants through communication with providers, center nursing staff, specialists, Clinical Nurse Manager, Clinical Director and all other ESP staff members involved in participant care.

• Completes nursing assessment and collaborates in the development of a comprehensive plan of care, as required by the Patient Care Team.

• Triages patients’ regarding illness and medical therapy and advises the patient/caregiver of the most appropriate action in consultation with a provider whenever necessary.

• Interacts with Clients and family members in a manner that adheres to the highest standards of care and professionalism.

• Builds trust and fosters smooth relationships with participant's and their families.

• Promotes patient confidentiality and right to privacy.

• Establishes and maintains, via provider order, an ongoing case management system that includes but is not limited to contacting patients with abnormal lab results or who miss appointments in accordance with ESP policies.

• Provides health teaching using appropriate information on health maintenance and disease management during each patient encounter according to ESP policies.

• Continuously updates his/her own clinical and professional knowledge and skills through formal and informal educational experiences.

• Must be able to travel to and from participants homes and the work site in a timely manner.

Supervisory Responsibilities - Home Care Nurse (RN):

Provides coaching and oversight to the Home Health Aides and Senior Home Health Aides.