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RN - PACE Team Support Nurse

Senior TLC (STLC) | Gastonia, NC | Full Time

Job Description


RN - PACE Team Support Nurse

Job Summary:

Has the responsibility for providing direct and indirect nursing care to participants.  Responsible for providing support to the STLC Nursing Teams as assigned. Works under the direct and indirect supervision of the Center Manager or designee but is independent in the application of advanced nursing knowledge and skills.  Manages complex clinical situations for which he/she is responsible.


Normal Work Week: Normally Monday - Friday during normal business hours but at times some evenings / weekends will be necessary.

Education: Graduate of an accredited school of nursing.

Experience: Has practiced nursing in the last 3 years; LPN experience with at least 24 months experience working with the frail elderly population.

Licensure, Registry or Certification Required: LPN currently licensed in North Carolina; presents credentials which demonstrate ability to meet performance criteria for RN.                                        

Key Responsibilities: (*denotes an age related skill or task):  Primary focus will be to support the Transitional Care Program of Senior TLC as requested by the Center Manager, Medical Director or as directed by the IDT team. 

The PACE Team Support Nurse will as have a secondary focus to provide back up or support to the Clinic Nursing

Team as needed based on census and the demands of the population that requires the most critical care/attention.

In Collaboration with the Nurse Transitional Care Coordinator performs the following as requested:

  •  Assists with the coordination of all approved respite stays at SNF facilities and communicating details with IDT members, participant, participant caregivers, and SNF staff.
  • Coordinate transition of participant from STR/medical respite to LTC when approved by IDT.

As requested by the IDT and or Medical Director, serves as liaison during emergency room visits by STLC participants.

  • Serve as liaison to assist coordination of discharge planning for STLC participants during hospital inpatient stays.  Includes transition to skilled nursing facilities and/or home.
  • Coordinate care of LTC participants with STLC provider to include appropriate SNF care and appropriate assessments to meet PACE guidelines.
  • Perform nursing assessments according to the NCBON standards for primary care providers in STLC clinic.
  • Performs home visits to sick participants to assess frailty as requested.

As Requested Provides Support to the Senior TLC Clinic:

  • Collects patient data and completes required forms with appropriate responses according to center standards; identifies patient’s overt problems/needs and sets priorities; identifies problems requiring further referral and/or follow-up; interprets and records latest diagnostic results; performs advanced nursing assessment using critical thinking skills. *
  • Care provided conforms to accepted practice standards; provides correct treatments/procedures and other care as prescribed and according to patient care standards; demonstrates understanding of age-related characteristics and needs of participants served; explains nursing procedures in appropriate forms; provides participant and family education in coordination of 24 hour care delivery; identifies emergency situations and independently initiates advanced therapy; acts as coordinator of patient care with other health care personnel and evaluates patient care measures instituted; understands and demonstrates respect for patient rights and utilizes established mechanisms for management of ethical issues in patient care. *Able to perform venipuncture for blood draws, IV insertion, and injections.  Familiar with various wound treatments and supplies.
  • Records patient care delivered as planned and any variation, with appropriate rationale; makes and records observations related to impending or associated problems; implements nursing measures related to impending or associated problems. * Able to become efficient with electronic medical charting, incident charting and various other electronic charting methods.
  • Participates in clinical review initiatives to ensure clinical team is functioning in accordance with polices procedures and program requirements.
  • Serve as a member of the IDT and attend regularly scheduled care planning sessions when appropriate.
  • Create, maintain, and update participant care plan as it pertains to appropriate nursing goals and interventions.
  • Perform on call nursing duties as described in on call policy.
  • Delivers Meds as requested.
  • Attends staff meetings and IDT meetings as required
  • Fill in /cover for any other licensed nurse position in STLC
  • Other duties as assigned


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