ESSENTIAL JOB DUTIES/RESPONSIBILITIES:
• Completes all training needed on timetables provided.
• Understand, asking any questions needed for clarity, the PCP-created care plan for each HPP senior being visited by a CP for a five-week period.
• Completes thorough home safety inspection during first visit with each HPP senior assigned.
• Reconciles and reports all prescriptions during each home visit.
• Checks and records health vitals including weight, blood pressure, heart rate, lung sounds, and blood sugar levels, as well as potential health challenges noted during the home visit and/or reported by each HPP senior visited.
• Immediately call CNMC PCP/CNMC Transitional Care Team Lead/CNMC Medical Director (cascade order) should HPP senior present with health risks that might warrant a same-day appointment at CNMC; a physician-directed medical intervention by CP, or a possible hospital visit.
• Interacts with EMS and ER personnel as necessary, and with expediency, to coordinate emergency care for any HPP seniors presenting with risk factors that warrant an immediate trip to the hospital.
• Creates and posts detailed File of Life documents for each HPP senior, noting all medications, allergies, and medical conditions of which emergency personnel should be aware, as well as contact info for family member or friend serving as emergency contact.
• Contacts and helps HPP seniors enroll in various social service programs as necessary to help close gaps in care.
• Documents and reports all findings/actions daily, to ensure all HPP senior visit reports are received by PCP/ Transitional Care Team Lead/Medical Director prior to CNMC weekly super huddles (each Tuesday). Include any recommendations to address/reduce health risk.
• Places at least a weekly courtesy well check | ombudsman resource call to each HPP assigned.
• Schedules and visits assigned HPP seniors weekly to complete social ecological assessments and to help ensure medical care instructions are being followed.
• Submits mileage and any out-of-pocket expense incurred weekly.
• Assists in the coordination of community service activities and special assignments.
• Administers appropriate patient care at the EMT and Paramedic skill level, as defined by Florida Statutes, in all emergency medical situations. This administration of care shall be based upon CNMC medical protocols set by CNMC Medical Director, and any other policies and/or procedures set forth by CNMC.
• Coordinates Fire-Rescue units, Police, and other community agencies making home visits.
• Maintains a proper and complete log of all activity.
• Ensures all reports are prepared in concise, complete, legible and accurate manner.
• Performs other tasks and/or duties as required or assigned by superiors.
• Contacts Police when appropriate.
• Reports any cases of neglect or abuse to Adult/Child protective services.
• Keeps any involved RN case managers/case workers informed, and coordinate their visits.
• Coordinates any needed mental health interventions leveraging community resources.
• Signs up Broward County HPP seniors for 211 Touchline.
• Educates HPP seniors on Aging and Disability Recourse Center | other social services.
• Other duties as assigned and modified at manager’s discretion.