<p>Job Summary: The Care at Home- Nurse Practitioner (CAH-NP) effectively manages complex</p> <p>high risk patients in their home setting to support complex and chronic care needs by 1)</p> <p>develop a trusting relationship with patients b) clinically assessing and treating patients c)</p> <p>empathizing and identifying the challenges patients and families face in their health care</p> <p>journey d) help patients and families in prioritizing and resolving the challenges in recovery by</p> <p>ensuring PCP appointments, assessing home situation, support available from family &</p> <p>caregivers, teaching patients and families about key disease conditions as relevant, ensuring</p> <p>education to help with medication adherence to ensure steady recovery and prevent</p> <p>unnecessary admissions. The CAH-NP will work in collaboration with the patients' family</p> <p>members, caregivers and PCP to solicit and ensure additional help required by patients as</p> <p>they move through their health continuum. In addition, CAH-NP will prioritize patients' medical,</p> <p>environmental and psychosocial needs with the goal of optimizing medical Care at Home-</p> <p>where every one of our patients want to be!</p> <p>Essential Duty # 1 - Percent: 85%</p> <p>Performs an initial comprehensive assessment during home visit while setting the foundation for a longitudinal medical Care at Home approach</p> <p>Ability to safely diagnose and treat patient in the home setting while in full collaboration with Primary Care Provider (PCP)</p> <p>Assist in closing HEDIS care gaps during home visit through Point of Care testing</p> <p>Performs home visit to assigned patients within 72 hours of discharge from SNF or Hospital</p> <p>CAH-NP will review the discharge plan from the hospital, assess patient to identify potential challenges that will result in patient returning to hospital, prioritize these challenges for resolution and be relentless in solving patient challenges</p> <p>Solving some of these challenges would require patient education to identify clinical decline early and engendering patient trust so that patients and families call Care at Home team early if they are having challenges, helping patients in resolving conflicting information about medicines and procuring rescue packs</p> <p>For select patients, it would require thoughtful communication with patients and families while bringing other experienced clinical colleagues e.g. Palliative care nurses, Pharmacists to help patients, Social Workers and Community Health Workers</p> <p>It is estimated 20% of patient contact would be telephonic while other 80% would require face to face interaction with patients and families at home; targeting min 4/visits daily at home</p> <p>Build partnership with Home Health/Visiting nurses and still differentiate themselves from the Home health with patient and families</p> <p>Essential Duty # 2 - Percent: 15%</p> <p>Manage patient panel of 150-200 patients. Meets assigned/expected patient contacts daily to assess and provide clinical care. In addition, CAH-NP coordinates care with PCP, Medical Director, CAH-Registered Nurse, Care Coordinator and participates in weekly Interdisciplinary Rounds to solicit help from others and share expertise with others</p> <p>Education/Experience:</p> <ul> <li>Completion of Nurse Practitioner (NP) accredited program </li><li>NP unrestricted active license for State of RI </li><li>2+ years of clinical NP experience preferred </li><li>AHA Basic Life Support </li><li>Demonstrated ability in developing trusting relationships </li><li>Comfortable working in patient's homes, respectful of patient autonomy and able to persuade patients and families </li><li>Strong clinical background to assess patients, educating families and patients </li><li>Ability to develop a plan to empower patients to gain disease state self management skills </li><li>Experience with Microsoft Office Word and Electronic Health Records </li><li>Valid unrestricted Driver's license </li><li>Master's Degree required. </li></ul> <p>Knowledge/Skills/Abilities:</p> <ul> <li>Willingness to travel throughout State of RI but mostly focused around Providence </li><li>Participate in on-call rotation </li><li>Ability to manage, prioritize and handle action items, care of 150-200 patients </li><li>Able to work independently and comfortable in making independent decisions while soliciting input from other colleagues, as needed </li><li>Ability to multi-task </li><li>Excellent written and verbal communication skills </li><li>Familiar/conversant with computers (emails, EMR, calendar, phone) to work autonomously </li><li>Maintain courteous professional attitude when working with internal and external customers. </li><li>Maintains member confidence and protects operations by keeping claim information confidential in compliance with HIPAA requirements. </li></ul>