Position Summary:

As a collaborative member of the IDT, and under the supervision of the San Diego PACE Home Care Coordination RN Manager, the SD PACE Home Care Coordinator HHA provides foundational support to the Home Care Coordination team. This role conducts home safety evaluations, coordinates and monitors IDT approved services, such as the delivery of meals, caregiver services and DME (durable medical equipment) for SD PACE participants. The Home Care Coordinator HHA is an advocate for participants' healthcare needs and preferences, ensuring that care is delivered in a person-centered and compassionate manner; working closely with participants, their families, and the interdisciplinary team to ensure that all aspects of unskilled homebased care is coordinated and aligned with the participants' goals and preferences. They liaise with care giver agencies, DME suppliers, etc. to coordinate schedules, monitor the delivery and quality of services/care provided, and make recommendations for adjustments to care plans as needed.

Essential Functions of the Job:

• Coordinate IDT approved meal delivery to client homes.
• Coordinate IDT approved Durable Medical Equipment and incontinence supply delivery to client homes.
• Coordinate IDT approved caregiver services for participants.
• As a member of the IDT, completes the Home Care Coordination care plan at enrollment and semi-annually thereafter.
• Conducts pre-enrollment, annual, semi-annual, and change of address home safety evaluations
• Documents and tracks actions, services, and service delivery status updates in designated logs and participant electronic medical records (EMR) in accordance with clinical, DHCS, and CMS regulations and guidelines.
• Review progress notes and documentation of the delivery of services, informing the IDT of any gaps in service for reconciliation.
• Upload progress notes, reports and care/vendor related documentation to the EMR.
• Communicates regularly with participants, their families, and other healthcare providers to ensure coordinated care delivery.
• Advocates for participants' healthcare needs and preferences and ensuring that care is delivered in a person-centered and compassionate manner.
• Provides support to SD PACE nurses in the coordination and delivery of meals, DME, caregiver services, etc.
• Collaborate with the interdisciplinary team members, including physicians, social workers, therapists, and other healthcare professionals, to ensure coordinated care for participants.
• Adheres to infectious disease precautions to prevent the spread of organisms.
• Attends center staff meetings and in-service educational training programs.
• Assists Home Care Coordination RN’s as requested.
• Conducts and documents monthly visits for homebound and RCFE participants.
• Conducts home visits as needed.
• Assists participants with surveys.
• Delivers supplies, equipment, grocery bags, and any other items as requested/needed.
• Generates and maintains reports on services provided for the participants.

Additional Duties and Responsibilities:

• Communicates and works effectively with participants and co-workers.
• Participates in interdisciplinary team meetings as needed.
• Adheres to SYHC and PACE attendance and punctuality policies and practices.
• Follows established PACE and ADHC departmental and position specific policies and procedures.
• Attends meetings as required and participates in committees as directed.
• Maintains health and safety standards and takes an active role in the Safety and Injury Prevention in the Workplace Program; maintains all records and documentation as required.
• Performs other related duties as assigned or requested. 

Job Requirements

Experience Required:

• One year of experience with the frail or elderly population

Education Required:

• CNA (Certified Nursing Assistant) and HHA (Home Health Aid) Certifications

Certifications Required:

• CNA Certificate 
• HHA Certificate (*must be willing to obtain HHA certificate within 120 days of employment and cost reimbursement is available)
• Valid CA driver's license and vehicle insurance
• CPR and First Aid (BLS) certification from the American Heart Association

Verbal and Written Skills Required to Perform the Job:

• Effective oral and written communication skills and the ability to follow written and oral instructions
• Attention to detail when typing and proofing materials
• Ability to communicate effectively and work collaboratively

Technical Knowledge and Skills Required to Perform the Job:

• Basic computer skills including Microsoft Suite, Outlook, and Excel
• Highly Organized, highly responsive, takes initiative, ability to work collaboratively as a member of the team while independently executing tasks
• Must possess the skills necessary to coordinate and evaluate services for geriatric participants 
• Must have a firm understanding of the Home Health Aide scope of practice and operate only within scope

• Professional and personable demeanor to maintain excellent working relationships
• Strong organizational skills with excellent attention to detail
• Ability to solve problems and identify both opportunities and potential challenges
• Maintain confidentiality and discretion and deal effectively and tactfully with staff, patients, and the public

Equipment Used:

• Company supplied computer/laptop, printer/fax, telephone, cellphone, iPad, and other general office equipment

Working Conditions and Physical Requirements:

• Continuous standing, walking, and twisting
• Occasionally lifts pushes and/or transfers participants of approximately 100 to 200 pounds
• Exposed to elements of health-related work (accidents, injuries and illness)
• Travel to participant homes, SYH sites, and San Diego PACE sites frequently

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.

About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment.  Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.