Health @ Home, an innovative home-based primary care program, in partnership with the Neighborhood Health Plan of Rhode Island and patients primary care provider team, delivers evidence-based practices that are both high quality and cost-effective to improve the quality of life to Rhode Islands older adult population. Home visits are performed by an interdisciplinary team consisting of Nurse Practitioners, Registered Nurses, and Community Health Workers. Clinical rounds are facilitated by the Medical Director weekly, and collaborates with case management, pharmacy, and behavioral health departments to identify barriers to patients have navigating the health care system, with the goal to reduce hospitalizations, and improve the quality life of NHPRI members.
This roles primary responsibility is to provide a highly coordinated, comprehensive approach to Neighborhoods plan members health care needs by providing patient centric home-based primary care to members that are in need of more tailored care due to chronic medical conditions and social determinants in order to enhance the patient experience, the health of the community, and decrease total medical costs.
The Nurse Practitioner manages the care of members in accordance with the Nurse Practitioner standards of care (assessment of health status, diagnosis, development of plan of care and treatment, implementation of treatment plan and evaluation of member status). Clinical management is conducted in collaboration with other health care team members, including patients primary care provider and team. Performs home-based comprehensive physical assessments of complex and chronically ill members while building trusting relationships. The NP teaches members, families and caretakers how to provide safe, effective care and promote members' optimum function. Uses teaching methods appropriate to the situation, learning needs, readiness and ability to learn, language preference and cultural values and beliefs. Care will primarily be provided in the members home, however, they may provide support in other facilities as needed.
Responsibilities include, but are not limited to the following:
Qualifications
Required:
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