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Fallon Health Nurse Practitioner in Geriatric Care - Elder Services Day Program (PACE Program) - Growing Service! in Springfield, Massachusetts


About Summit ElderCare :

Summit ElderCare©, offered by Fallon Health, is the only program of its kind in Central Massachusetts and is one of eight PACE programs in the State. Currently there are 124 PACE Organizations nationwide across 31 states operating 255 PACE centers. Summit ElderCare© provides a combination of medical, social and insurance services using an interdisciplinary team approach to help older adults avoid nursing home placement. The program offers outpatient medical care, social day programming, home care and comprehensive insurance coverage with no co-payments or paperwork for participants. Our physicians and nurse practitioners are able to provide care for the frail elder not available in any other setting. Our comprehensive program is not constrained by the usual insurance company rules and benefit limitations and we have the capacity to offer services that are not often covered by other plans.

Position Overview:

Our Physicians have flexibility to devote as much time as needed for the clinical and social needs of our participants and their caregivers to provide individualized quality care by a team of geriatric care professionals who work together with participants and caregivers to address each individual's specific needs. This team of professionals is an essential component of the Summit ElderCare PACE program.

The team uses a collaborative approach to care planning and is called the Interdisciplinary Team (IDT). The IDT is comprised of Providers (MD/DO and NP/PA), Nurses, Social Workers, Physical and Occupational Therapists, Dieticians, Health Aides, Recreation staff, Home Care and Transportation Coordinators and Site Administrator. This approach to care is the gold standard for complex and frail older adults who wish to avoid nursing home placement.

Summary :

Manages a primary care panel of participants and provides continuity primary health care to PACE participants that reside in the community or long-term care setting with a focus on goal oriented, person-centered care, disease progression, disease prevention, wellness and management of chronic and episodic illness consistent with the participant’s goals of care. Works in close collaboration with all members of the PACE Interdisciplinary Team.

Establishes realistic goals and helps develop and manage individualized plans of care with the IDT team for program participants.

Provides primary health care to Summit ElderCare program participants focusing on disease prevention, wellness and management of chronic and episodic illness. Addresses advance directives in a participant-focused manner focusing on what matters most.

Works in close collaboration with the program’s interdisciplinary team to establish realistic goals and care plans and develop and manage individualized plans of care for program participants.


Primary Job Responsibilities:

  • Performs post enrollment visits, biannual exams of participants and appropriately identifies and documents problems/issues in medical records

  • Evaluates episodic illnesses and issues appropriate diagnostic and therapeutic orders

  • Collaborates with physicians and other interdisciplinary team members to manage episodic and chronic medical needs of participants

  • Addresses and documents Advance Directives/MOLST discussion for participants a minimum of annually and when a change in participant condition occurs

  • Performs diagnostic, therapeutic and nursing intervention as indicated

  • Provides continuity in monitoring of chronic, stable illnesses

  • Implements the participant plan of care in a safe and effective manner

  • Participates in interdisciplinary team meetings

  • Evaluates effectiveness of previously implemented treatment

  • Conducts home and nursing home visits as indicated

  • Maintains accurate documentation and coding of all services provided according to professional standards

  • Identifies utilization and service delivery problems and participates in identifying a resolution

  • Identifies grievances and brings forward to leadership

  • Participates in quality assessment activities including but not limited to record reviews, outcome measurement and review/revision of policies and procedures

  • Provides education and training to participants, caregivers and staff in relevant topics

  • Acts a resource to program staff and participates in defining care standards and practices

  • Serves on appropriate committees, participates in all site and provider staff meetings including behavioral rounds and psychiatric rounds as indicated.

  • Enhances personal professional growth and self-development through participation in professional activities including educational programs, current literature, in-service programs, trainings and workshops.

  • Maintains BLS certification and professional certification as appropriate.

  • May be asked to perform other duties that align with Fallon Health’s mission, including but not limited to participation on clinical committees, providing education, quality initiatives and/or other activities.



  • Master’s degree required. Graduate of an accredited Nurse Practioners program


  • Licensed by the Commonwealth of Massachusetts Board of Registration in Nursing. Access to reliable transportation to carry out duties, both center-based and community, is required


  • One to three years of Nurse Practitioner experience preferred with at least one year of experience in geriatric care.

  • Experience working in a healthcare setting as a member of a professional clinical team.

  • Experience with care coordination.

  • Other: Satisfactory Criminal Offender Record Information (CORI) results

About Fallon Health

Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Location US-MA-Springfield

Posted Date 1 month ago (9/29/2021 9:23 AM)

Job ID 6526

# Positions 1

Category Nursing