Nurse Practitioner

Job Details

Description

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:

• Perform 4-6 daily home visits that utilizes the Institute for Healthcare Improvements, Age Friendly 4M framework to provide evidence based care that aligns with what matters to older adults to better address the challenges in navigating the healthcare systems and improve their quality of life
• Evaluates the needs of each member in developing and updating a comprehensive individualized care plan in collaboration with team members, plan member, Primary Care Provider (PCP), specialists and other service providers
• Optimize chronic medical conditions, assess home environment and social determinants of health, educate patients and caregivers, and develop proactive care plans
• Makes home visits to monitor and track each members clinical status and delivers care in the home
• Perform acute care visits for potentially preventable ED transfers and hospitalizations
• Communicate and collaborate with primary care provider offices to offer home-visits for their most at risk, complex, vulnerable patients

• Continued assessments of the status of identified problems, response to treatment, compliance with the therapeutic regimes and medications as well as progress towards goals
• Understand the importance of quality metrics and interpret to improve health outcomes
• Delegates care by the registered nurse, community health worker, and behavioral health/social worker
• Orders and interprets diagnostic and therapeutic tests relative to members needs
• Prescribes and adjusts medications and treatments based on a sound understanding and interpretation of clinical indicators and findings
• Help members and caregivers understand their health condition(s) and develop strategies to improve their health and well being
• Observes safety and security procedures; reports potentially unsafe conditions

• Determines the need for consultation from specialists and make referrals as necessary
• Collaborates with multidisciplinary team members by making appropriate referrals to Care Management team and to behavioral health care services
• Manages both medical and behavioral chronic and acute conditions in collaboration with specialty providers and team members
• Collaborate with PCPs, Emergency Department (ED)s, Hospitalists, Discharge Planners and other allied care providers
• Coordinates and authorizes all skilled and ancillary services, including Durable Medical Equipment (DME) and supplies
• Works in collaboration with the PCP, providers and discharge planners to facilitate proper care and timely discharge to an appropriate setting
• Facilitates and/or participates in member care conferences and educational meetings
• Establishes and maintains an ongoing working relationship with providers and other appropriate community resources/agencies
• Facilitates staff, member and family decision making by providing educational tools
• Serves as the key contact and central coordinator of the health care team

• Documents member encounters, medical records, updates the EMR within established timeframes
• Documents plans, communications, rationales for plan changes and collaborative discussions
• Collaborates with Neighborhood staff in support of organizational objectives
• Other duties as assigned
• Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.

Qualifications

Qualifications

Required:

• Advanced Practice Registered Nurse (APRN) Licensure active license in state of Rhode Island
• Graduate of an accredited Nurse Practitioner (NP) Program
• Proven skills and knowledge base necessary for independent clinical decision making
• Demonstrated competency and experience delivering primary care to adults in underserved populations
• A high comfort level in providing care in the members home
• Strong organizational and documentation skills
• Strong problem solving skills and attention to detail
• Effective oral and written communication skills
• Intermediate skills in Microsoft Office (Word, Excel, Outlook) including electronic medical records (EMR)
• Dependability when necessary, commits to hours necessary to meet the needs of members
• Time flexibility - Must be willing to work nights and/or weekends when member.