Family Health Centers of San Diego·San Diego, California
Conduct home visits to evaluate prospective participants for PACE eligibility and perform level of care assessments. Develop and audit individualized home care plans in collaboration with an interdisciplinary team and RN manager.
For more than 55 years, Family Health Centers of San Diego’s (FHCSD) mission has been to provide caring, affordable, high-quality health care and supportive services to everyone, with a special commitment to uninsured, low-income and medically underserved persons.
FHCSD is one of the top 10 largest federally qualified health centers (FQHCs) in the country.
We operate more than 90 sites across San Diego County, including 29 primary care clinics, 23 behavioral health facilities, 10 physical rehabilitation clinics, nine dental clinics, five vision clinics, four outpatient substance use treatment programs, three mobile medical units, two mobile counseling centers, two urgent care centers, and a pharmacy.
Our staff provides care to over 227,000 patients each year, of whom 91% are low-income and 29% are uninsured.
FHCSD provides care to all.
Services include, but are not limited to adult care, chronic disease management, pediatrics, comprehensive women’s care including obstetrics, dental, vision, case management, physical rehabilitation, speech therapy for children, vaccinations, infectious diseases, behavioral health, substance use counseling and a host of specialty services including cardiology, podiatry, endocrinology, dermatology, among others.
FHCSD also offers supportive services to those who are unsheltered and in need of intensive case management.
The breadth of our clinic locations, services and programs has grown over the last five decades, making us the largest community clinic provider of health care to the uninsured in the county and one of the top 10 largest community clinic organizations in the nation.
We are also the largest health care safety-net provider, largest school-based health care provider and the largest mental health provider in the San Diego region.
Accompany Business Development Representative to initial home contact meeting. Evaluate for safety and stability of home environment and assess that prospective participant is appropriate for PACE using established criteria and guidelines. Determine if prospective participant is currently enrolled in any State funded programs that would preclude them from enrolling in PACE including but not limited to SD County in-home support service (IHSS) and DMH programs. Educate potential participant that they are not eligible to be submitted for PACE until they are disenrolled in any disqualifying state programs. Provide alternative resources if available. Present prospective participants to interdisciplinary team (IDT) for approval to move to Level of Care assessment. Provide individualized resources to any prospective participant that is not eligible for PACE. Provide education on criteria to be met that might qualify prospective participant to enroll in PACE. (Ex: disenroll in other state programs, move into a safe and stable home environment, move into an alternate living facility (ALF) or Board and Care facility if 24- hour supervision required.) Perform an in- home level of care assessment for prospective participants following established guidelines. Assess participant goals and wishes for participating in PACE program. Complete DHCS LOC form and Certification form and submit to RN Manager for review and submission to DHCS. Upon approval to participate in program, determine home health and home care needs in an hour of care format using data and observations from initial home assessment and LOC assessment. The individualized home care determination will be established through the home care service/hour tool and clinical judgement. Participate in pre-enrollment mini- assessment to review the home care needs assessment with potential participant including family or other support person(s). Review the participant goals and wishes and determine that they have not changed. Together with the potential participant and their family or support person(s), establish a home care plan of care. This is to be completed prior to the potential participant signing the enrollment form. After enrollment, collaborate with home care supervisor to review established home care plan of care to be implemented. In collaboration with RN manager, audit, and review home care services for compliance to care plan at a minimum of every 3 months. Plan of care should be regularly updated as participant meets goals or require new goals to be established. In collaboration with RN Manager, review outsourced home care services and home health services to ensure services are being delivered as ordered and discontinued when appropriate on a weekly basis. Audit home health charts for completion. Performs other duties as assigned.
Travel required. California State Board RN License required. Current American Heart Association healthcare provider CPR (BLS), or Advanced Cardiac Life Support, Advanced Trauma Life Support, or Advance Resuscitation Training. Graduation from a recognized RN/BSN program. High School Graduate (or GED equivalent). Traveling between sites and other locations is required as an essential function of the job. Must have a car, a valid California driver’s license, and proof of minimum levels of car insurance as required under California law, although limits of $100,000 are recommended. An acceptable driving record is also required. California law requires all drivers to obtain a valid California driver’s license within ten days of establishing residency. Mileage and other reimbursement governed by policy. 1 – 2 years of experience working with the older adult population. Clinical competency with the older adult population including physical and cognitive assessments preferred. Experience in Home Health Care preferred. Ability to work effectively in a team environment. Demonstrated ability to communicate effectively and openly with other interdisciplinary team members on participant status and needs. Must be able to multi-task, be flexible, ensure accuracy, and meet changing priorities in a fast-paced, high workload environment. Basic computer literacy to comply with department needs and expectations (i.e., E-HR documentation, obtaining background information and reports, following up on appointments, etc.). Bilingual English/Spanish preferred.
Market context
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