Nurse Practitioner (NP)

PACE (Program of All Inclusive Care for the Elderly) San Marcos, California


Founded by philanthropists Gary and Mary West, West Health, and its affiliated organizations, focus on the mission of lowering the cost of healthcare and enabling seniors to successfully age in place with access to high-quality, affordable health and support services that preserve and protect their dignity, quality of life and independence. West Health is advancing efforts to expand Programs of All-Inclusive Care for the Elderly (PACE®) with the opening of a new, state-of-the-art PACE center located in San Marcos, CA. This center will be entrepreneurial in nature and will focus on innovations and bringing new processes to the traditional PACE environment.

Gary and Mary West PACE is a non-profit that delivers medical, social, and behavioral services to the frail elderly in North County San Diego. PACE® is a national model of person-centered, integrated care that enables frail older individuals the ability to age in place safely in the community. The PACE® Model of Care serves as both a health plan and healthcare provider to enrollees, using an interdisciplinary team approach to providing medical care, behavioral health, social support services, and end of life care. The PACE® model of care is nationally recognized among consumers, healthcare providers and government leaders as the most innovative, accessible, valuable and effective model of care promoting the highest level of independence for older individuals with significant healthcare needs who are also nursing home eligible.

I. Role Summary:

Under the supervision of the Medical Director and in collaboration with PACE Physicians and Community-Based PACE Physicians provides assessment, planning, primary care, and continuous medical coverage to PACE participants in an interdisciplinary team environment and in accordance with Gary and Mary West PACE (GMWP) standards.

II. Duties and Responsibilities:

• Provide primary care and acute illness evaluation and treatment for participants in collaboration with PACE Physicians and Community-Based PACE Physicians
• In collaboration with a physician, perform in-person comprehensive assessments (initial, semi-annual and unscheduled) on participants and coordinate with the IDT to develop a comprehensive care plan for each participant
• Collaborate with physician(s) and IDT in discharge planning from acute or long term care settings
• In consultation with the PACE Physician and/or Community-Based PACE Physician, refer participants to medical specialists as indicated
• In collaboration with the PACE Physician and/or Community-Based PACE Physician, manage the care of participants in the nursing home, making regular visits as dictated by GMWP standards and participant need
• Be an active member of the IDT communicating participant changes, collaborating on care planning decisions and coordinating 24-hour care delivery
• Work collaboratively with PACE Physicians, Community-Based PACE Physicians and other members of the IDT to ensure effective care coordination
• Participate in rotating night and weekend call
• At the direction of the Medical Director, review outcomes and utilization data, including review of necessity of hospitalizations and use of specialists; establish best practices with the Medical Director, and collaborate with clinical staff, PACE Physicians, Community-Based PACE Physicians, and IDT to make policy and procedural improvements to reduce unnecessary utilization and improve participant health
• Protect privacy and maintain the confidentiality of all company procedures and information about employees, participants, and families
• Follow GMWP policies and procedures and participate in any required QI activities, staff training, and meetings
• Maintain professional licensure and certifications
• Act only within the scope of practice

III. Qualifications and Requirements:

• Graduate of an accredited school of nursing
• RN State License
• Certification as a Nurse Practitioner with prescriptive authority

• Current Basic Life Support (BLS) training
• Current driver’s license and proof of auto insurance

Skills and Experience:
• Minimum of 2 years working with the frail or elderly
• Ability to build strong working relationships with other providers and the care team
• Creative and enthusiastic commitment to the “triple aim” – dedication to improving the experience, health, and value for PACE participants
• Current knowledge of chronic care/geriatric issues and best practices
• Work well in a managed care environment with an interdisciplinary team (IDT)
• Ability to process information accurately and timely
• Excellent clinical, organizational, and communication skills in settings with frail, elderly participants, their families, and the IDT
• Working knowledge of PACE regulations preferred

Medical Clearance:
Employees must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.

Position-specific competencies for the Nurse Practitioner will be met prior to assuming participant care.

IV. Physical Demands and Working Conditions:

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this role. In compliance with ADA requirements, reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

• Work Environment: Employee must be able to work effectively within an interdisciplinary team model, interfacing and collaborating with a wide range of clinical and social services disciplines who work together to manage the PACE participants' care. The work setting is in an Adult Day Health Center, primary care clinic and participant home environment with moderate noise levels and controlled temperatures.
• Physical Requirements - Requires corrected vision and hearing to normal range. Must be able to communicate with all staff, vendors, and clients. Requires manual and finger dexterity and eye-hand coordination; the ability to use department equipment. Requires lifting/carrying up to 65 lbs. and pushing or pulling 150 lbs. using appropriate body mechanics and equipment, with reasonable accommodation if needed.
• Visual, Hearing and Communication Requirements - Requires corrected vision and hearing to normal range, with or without reasonable accommodation. Ability to communicate by way of the telephone with participants, customers, vendors, and staff.
• Pressure Factor - Requires working under stressful conditions. Working conditions may be noisy and crowded and fluctuating indoor temperatures. Moderate pressure to meet scheduled deadlines. Potential for exposure to verbal aggression by clients, vendors, and staff. 

Job offers are contingent upon a successful pre-employment drug screen, background check, and physical assessment.

Gary and Mary West PACE provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, pregnancy, military and veteran status, age, physical and mental disability, genetic characteristics, gender, gender identity, gender expression or sexual orientation or any other considerations made unlawful by applicable state or local laws.