Under the direction of a Care Manager, the Community Health Nurse (CHN) provides skilled care and routine clinical nursing assessment visits to PACE members and families utilizing all elements of the nursing process and in compliance with applicable laws, regulations and organizational policies. The CHN primarily provides nursing visits in the member’s home in the community but can routinely visit members in the PACE center, hospitals, nursing homes, and other alternate setting as deemed necessary for care coordination consistent with the PACE model of care. The CHN is a core interdisciplinary team (IDT) member who assigned to a PACE member in compliance with CMS PACE regulatory requirement
1. Knows and conforms to the law governing the practice of professional nursing and provides professional nursing care using all elements of the nursing process.
2. Assesses and evaluates the health care needs of patients and families with consideration regarding physiological, psychological, social and environmental factors.
3. Identifies complete, accurate and logical Uniform Assessment System (UAS) for NY and appropriate sequencing of diagnoses in collaboration with the PCP to maintain compliance with state and federal regulations.
Maintains constant and ongoing communication with the assigned Care Manager in regards to the participants health status, clari