(Archived) Home Visit Nurse Practitioner - Springfield, MA

Our team is primarily responsible for providing longitudinal care coordination, care management, and/or care delivery to a dedicated panel of individuals with significant medical, behavioral, and social complexities that require intensive clinical support.

The NP, Care Partner will provide ongoing chronic disease management, urgent visits, promote preventative care and wellness, and provide end of life/palliative care. Role also includes a compendium of care management/ care coordination functions encompassing the development and implementation of the member centric individualized care plan along with authorization of appropriate durable medical equipment and services.

Responsibilities

• Within a defined time period post assignment, perform a comprehensive annual assessment taking a detailed history, performing a physical examination, and documenting appropriate diagnosis with a plan to address unmet needs associated with the diagnosis. The onboarding Annual Comprehensive Assessment also ensure capturing appropriate High Risk Codes under guidelines
• On an annual basis, conduct an Annual Comprehensive Assessments on assigned panel members, taking a detailed history, performing a physical examination, and documenting appropriate diagnosis in order to ensure capture of high risk codes under guidelines.
• Facilitate, and/or deliver preventative care to members according the the guidelines deemed appropriate by Clinical Leadership. Guidelines may vary based on the individual make up of the member and is based on age, co morbidities ,etc. Identify and initiate a plan to resolve areas of opportunity to meet quality metrics.
• Provide regularly scheduled follow up visits for the management of chronic disease or end of life/palliative care. Visits are inclusive of a history of present illness, review of systems, physical exam, ordering of appropriate studies and tests, identification of a definitive diagnosis, adjustment or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation.
• Perform episodic urgent medical/ behavioral health visits to ensure that panel members are given timely and appropriate medical care in order to avoid emergency room or hospitalization. Visit includes a detailed history of present illness, review of systems, physical exam, ordering of appropriate studies and tests, identification of a definitive diagnosis, development of a treatment plan, and evidence of follow up through timely documentation.
• In order to decrease risk of readmission, perform post discharge visits on panel members within 48-hours of discharge from either an acute care facility or a skilled nursing facility; perform detailed medication reconciliation, adjust medications as indicated, and ensure appropriate LTSS are in place. Visit will include history of causes for recent admission, review of systems, physical exam, ordering of appropriate diagnostic tests or studies, determination of a diagnosis, development of a treatment plan, and a member centric “action plan” which will provide education and guidance encouraging self management with future episodes.
• Liaise with PCPs/ Specialists, as needed
• Provide Intermittent Skilled Care as necessary (e.g., wound care,)
• Ensure appropriate documentation of visits and activities within our central enrollee record and within the record of partners as indicated. This is accomplished through either documenting oneself in multiple systems, or utilizing internal resources that will facilitate documentation.
• Within a defined (dependent on the acuity of the member’s needs) period of time post assignment, develop a member centric care plan which is inclusive of appropriate long term support services and optimizes available resources to improve or maintain health and functional independence in the community.
• On a semi annual or annual basis, review and update the member centric care plan and adjust as indicated. Review care plan with the member and ensure that it is available to the member.
• Adjust the member centric plan of care as necessary based on a significant change in condition. A change in condition is an event (hospitalization, acute illness, etc. ) which results in either a short or long term change in need (examples include adding in Palliative care, increasing personal care hours short term post hospitalization, or purchasing high cost durable medical equipment for a non reversible functional change)
• Utilizing Clinical Decision Support Tools, team meetings, and consultation with specialists, authorize proposed equipment and/or services for the implementation of the individualized plan of care. Participate in utilization and case review as necessary.
• Utilizing and depending on our internal resources, ensure that the plan of care is implemented in a timely manner.
• Perform defined functions of the authorization process as indicated by our policies and procedures.
• Conduct annual/6 month MDS assessments and annual comprehensive assessments for panel members based on program. (every 6 months for SCO, annually for One Care)
• Perform MDS assessments when rating category needs to be adjusted
• Act as a mentor to other team members to help promote/foster accountability, reliability, and independence among the other team members
• Provide consultation and support to other members of Care Team
• Participate in Team Case Review
• Maintains appropriate written and oral communication on a timely basis, completing documentation within 24 hours of activity, and returning non-urgent calls within 48 hours
• Actively participate in the evaluation of own performance and progress
• Participate in activities and education to maintain and advance competency

Qualifications

• Minimum Education: Master’s Degree in Nursing or Physician Assistant
• 2-3 years of hands on clinical experience, defined as:
• No NP but with substantial (5 or more years as an RN in a high-touch clinical environment or home care)
• 1-2 years of NP experience (preferably in primary care)
• Board Certified Nurse Practitioner or Physician Assistant with licensure in good standing in the Commonwealth of Massachusetts.
• Will be required to pass our credentialing process.
• Current Mass Controlled Substances License required
• Current DEA Controlled Substances License required
• Current CPR or Basic Life Support (BLS) Certification