Medical- WW- Home Visiting Nurse Practitioner - Integrated Care Management

Heading:
Title: Home Visiting Nurse Practitioner - Integrated Care Management    Reports To: Medical Director, Value-Based Care 
Department: ICM

General Responsibilities:
The Home Visiting Nurse Practitioner - Integrated Care Management (ICM) is a member of the Integrated Care Management department; a multi-disciplinary team comprised of nurse care managers, community health workers, behavioral health clinicians, and peer recovery support specialists. The ICM Home Visiting Nurse Practitioner is responsible for providing primary medical care as a home-based extension of the primary care provider care teams, within the limits of the training of a Nurse Practitioner to patients referred to the home-visiting program and Integrated Care Management team. The Home Visiting Nurse Practitioner may also be assigned to perform duties at Thundermist Medical Respite and other Thundermist activities that are supported by the Thundermist Accountable Entity. The Home Visiting Nurse Practitioner is a licensed, autonomous provider executing professional clinical judgment in the care of his/her patients according to the guidelines, policies and procedures set forth by the agency.

Required Qualifications:
1.    Rhode Island RN and APRN licensure
2.    ANA Certification in Family Medicine or Adult/Geriatrics
3.    Ongoing CEU to update skills/therapies.
4.    Ability to work independently and effectively in a team environment.
5.    Ability and willingness to travel the State of Rhode Island, surrounding areas, and where Thundermist patients live.
6.    Valid driver's license and reliable transportation with proof of RI minimum requirements of auto insurance (including a 100/300 K Rider) to utilize your automobile for work purposes.  
7.    Bi-lingual desirable.
8.    BLS Certification

Primary Contacts:
External:    Frequency:
1.    Hospitals    Daily
2.    Providers    Daily
3.    Outside Agencies    Daily
4.    Laboratory Staff
5.    Patients in their home    Daily
Daily
    
Internal:    Frequency:
1.    Patients    Daily
2.    Providers/PCP    Daily
3.    Staff and Medical Staff    Daily
4.    Members of ICM Team    Daily
5.    Administrative Staff      Periodically

Physical Effort/Environment:
Moderate physical activity; walking, standing, and stooping. May require climbing several flights of stairs and carrying personal technology such as laptop and small clinical equipment. Must be comfortable entering and providing care within the home environment of patients. Travel within Rhode Island and surrounding areas with heavy focus on Woonsocket, West Warwick, and South County.
Potential exposure to bloodborne pathogens, respiratory disease, and other infectious diseases, and other biohazardous materials requiring universal standard precautions for medical practitioners. Manual dexterity needed for certain medical procedures.

Work Schedule Demands:
31 Clinical Hours, 1 hour of Nurse Practitioner Collaborative Meeting, and 8 hours of administrative time per week (40 total hours per week). 30 visits per week target, 20 visits minimum.
Communication Skills:
Exceptional oral and written communication skills needed. Proficiency in all applicable medical terminology. Bilingual capacity in Spanish is a plus. Strong interpersonal skills are needed.
Confidentiality of Information:
Access to patient medical records, selected budget and financial information.
Significant Job Functions:
Clinical
1.    Patient Care - history, physical exam, management of acute and chronic illness of high-risk adults with complex chronic health conditions. There will be three primary types of visits:
i.    Providing high quality home-based and medical respite care for medically complex patients who are experiencing temporary or long-term physical or behavioral health issues impacting their ability to be seen in an office-based primary care setting.
ii.    Supporting recently hospitalized patients as they transition home by performing post-discharge home or medical respite visits to reconcile medications, assess patient's clinical status, and ensure that they have access to all necessary home services.
iii.    Providing home-based or medical respite care as the primary care provider when necessary to support end-of-life care with a goal of maintaining independent living and continuing as patients of Thundermist. Patients to be reviewed on a case-by-case basis. 

2.    Maintenance of complete and accurate patient records. Completion of medical notes in a timely manner for claims processing.
Administrative
1.    Attending Nurse Practitioner Collaborative Care Meetings weekly
2.    Attending Medical Respite Meetings weekly