Job Location
Smithfield, RI - Smithfield, RI
Position Type
Full Time
Education Level
Masters Degree
Travel Percentage
Daily
Job Shift
Daytime
Job Category
Professional / Experienced
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 for Rhode Island's 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, collaborating with case management, pharmacy, and behavioral health departments to identify barriers patients have in navigating the health care system, with the goal to reduce hospitalizations and improve the quality of life of NHPRI members.
This role's 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 the 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. 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 utilize 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.
- Evaluate 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.
- Make home visits to monitor and track each member's clinical status and deliver 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.
- Delegate care by the registered nurse, community health worker, and behavioral health/social worker.
- Order and interpret diagnostic and therapeutic tests relative to members' needs.
- Prescribe and adjust 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.
- Observe safety and security procedures; report potentially unsafe conditions.
- Determine the need for consultation from specialists and make referrals as necessary.
- Collaborate with multidisciplinary team members by making appropriate referrals to Care Management team and to behavioral health care services.
- Manage 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.
- Coordinate and authorize all skilled and ancillary services, including Durable Medical Equipment (DME) and supplies.
- Work in collaboration with the PCP, providers, and discharge planners to facilitate proper care and timely discharge to an appropriate setting.
- Facilitate and/or participate in member care conferences and educational meetings.
- Establish and maintain an ongoing working relationship with providers and other appropriate community resources/agencies.
- Facilitate staff, member, and family decision making by providing educational tools.
- Serve as the key contact and central coordinator of the health care team.
- Document member encounters, medical records, and updates the EMR within established timeframes.
- Document plans, communications, rationales for plan changes and collaborative discussions.
- Collaborate 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
Required:
- Advanced Practice Registered Nurse (APRN) Licensure active license in the 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 needs arise.
- Must have access to reliable transportation. If using a personal vehicle, must have a valid, active driver's license and current auto insurance.
- Requires 24/7 telephonic on-call service and periodic on-call for home visits must be able to respond to calls within 1-2 hours.
- Compliant with State of RI immunization regulations for health care workers.
Preferred:
- Bilingual.
- Nurse Practitioner clinical experience.
- Medicare/Medicaid experience.
Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.
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