Geriatric Resources for Assessment and Care of Elders (GRACE) Registered Nurse

Job Description

Job Description

Apply on line at http : / / www.alohacare.org / Careers / Default.aspx

The Company :

AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers.

Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all.

This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment.

As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii .

The Culture :

AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work / life balance, continuous communication and a generous benefits package.

AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs.

AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work / home balance for its employees.

Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings.

AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.

These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.

The Opportunity :

The Geriatric Resources for Assessment and Care of Elders (GRACE) Registered Nurse is responsible for coordinating geriatric care for AlohaCare adults 50 years of age or older with geriatric conditions receiving health care in an affiliated health care system.

GRACE Team Care offers home-based geriatric assessment and care management as part of an interdisciplinary team for individuals who have geriatric conditions.

In collaboration with the GRACE social worker, the primary care physician and the GRACE interdisciplinary team, the GRACE registered nurse evaluates an adult’s medical and functional status and works to implement a comprehensive treatment plan of coordinated care that supports the individual’s goals, strengths and preferences and maximizes the health potential and quality of life of the member.

The GRACE team’s working relationship and communication with the Primary Care Team is key to the success of the GRACE program The GRACE registered nurse is expected to coordinate care with the PCP and GRACE support team for vulnerable older adults who are at risk for geriatric complications and functional decline.

By engaging and educating families and caregivers involved in the adult’s care, the GRACE registered nurse works to promote the individual’s maximum functioning and quality of life.

The catalyst of the GRACE model is the GRACE support team which consists of the social worker and registered nurse. In collaboration with the PCP, the support team works closely together to assess the individual, develop and implement a care plan, evaluate and treat geriatric conditions, and provide longitudinal care management and coordination of care.

Primary Duties and Responsibilities :

• Performs in-home face-to-face visits at a minimum of initially and annually or with change in condition (includes virtual telehealth visits) to assesses the Member’s clinical, health, and psychosocial status based on a history, physical examination, and comprehensive functional assessment and documents in clinical case management system;
• Performs preventative screening procedures to identify medical and health risks and needs;
• Involves the Member’s primary caregiver(s), significant other, and family as appropriate in the assessment;
• Collaborates with GRACE team to develop an individualized care plan (ICP) with goals that are patient-centric;
• Solicits input into the ICP from a multi-disciplinary team of a social worker, geriatrician, pharmacist, and mental health liaison.
• Monitors the effectiveness of the ICP, modifying it as necessary to achieve the goals set forth in the ICP;
• Follow up on any care plan activities until completion;
• Updates the ICP, based upon assessed needs;
• Provides education to the Member and caregiver about health promotion, disease management, care gaps, geriatric conditions, medication adherence, and recommended therapies or interventions;
• Activates GRACE protocols and team suggestions for care related to geriatric conditions;
• Provides supportive counseling with the Member and caregiver in understanding the illness and coping with its impact, as well addressing end-of-life and bereavement issues;
• Evaluates the need for specialized behavioral health care and, if necessary, initiates a referral;
• Collaborates with the GRACE SW to address social determinants of health and referrals to relevant programs to address;
• Meets with the PCP to discuss the ICP, prioritize interventions and coordinate implementation;
• Attends additional provider meetings as needed to review, modify and prioritize the ICP;
• Refers the Member to physicians, other health professionals, community agencies and programs on an as needed basis;
• Attends weekly GRACE interdisciplinary team meetings to review the implementation of the ICP and assists with facilitation of those meetings;
• Enters all contact with the Member and his / her family or care-givers in the electronic record to ensure information on the Member is shared with the health care team;
• Performs team reviews at one, two, three, six and nine months following the initial team care planning conference and additional team reviews if the member is hospitalized or has an emergency department visit;
• Provides ongoing GRACE coordination and continuity of care for GRACE members;
• Shares responsibility with GRACE Social Worker to complete monthly follow up calls with GRACE members;
• Engages new Members and meets with provider agencies to promote engagement in the GRACE program;
• Meet with member at PCP appointment when needed;
• Carries out role with a relatively high degree of autonomy, exercising independent judgment and initiative in coordinating care in complex situations.
• Complete required monthly reporting;
• Attends monthly GRACE Provider meeting;
• Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules and regulations regarding confidentiality.

Employees have access to AlohaCare data based on the data classification assigned to this job title.

Requirements :

• 2 years’ experience with the geriatric population and / or 3 years of direct inpatient care
• Licensed RN in state of Hawaii
• Outstanding interpersonal and communication skills
• Ability to solve problems and make decisions independently
• Ability to work in high stress environment at times, with pressure of multiple deadlines
• Possession of valid driver’s license with access to a reliable insured automobile
• First aid and CPR Certification
• Initial and annual TB clearance certification
• Requires use of personal mobile device (Android or IPhone manufactured in the last 4 years) compatible with our application and e-mail systems

Preferred Requirements

• Experience with QUEST and Medicare programs and working knowledge of managed health care
• Multilingual preferred
• Proficient with Microsoft word and excel

Mental, Physical and Environmental Demands :

• Medium Work : Walking, standing and exerting up to 40 pounds of force occasionally, or up to 25 pounds of force frequently, or greater than negligible up to 10 pounds of force constantly to move objects of force occasionally and / or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects.
• May require prolonged sitting up to 4 hours
• Requires operation of a computer workstation including keyboard and video display terminal.
• Requires driving to member’s homes or provider settings
• Inside working conditions
• No environmental hazards
• Requires operation of general office equipment to include PC

Salary Range : $78,000 - $83,000 annually

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws.

Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military / veterans status, or other characteristics protected under applicable state and federal laws, regulations, and / or executive orders.