Provides primary medical management for Immanuel Pathways Participants. Completes initial and reassessment for Immanuel Pathways Participants and develops and implements appropriate plans of care. Follows protocols developed by Immanuel Pathways in accordance with State and Federal regulations. Evaluates participant’s expressed concerns and recommends appropriate treatment to the Interdisciplinary Team (IDT) for decision. Provides participants and their caregivers/authorized representative with instruction and education. Functions as a member of the IDT and informs the IDT of the medical condition of each participant, remaining alert to pertinent input from other team members, participant’s caregivers/authorized representative, as well as documenting changes in a participant’s medical record consistent with documentation policies. Performs rounds in the Immanuel Pathways contracted provider locations ie; nursing home, hospital and assisted living. Must notify Immanuel Pathways and State Board of Nursing of change in residence. Supports and lives out Immanuel’s Mission and CHRIST Promises.
Key Responsibilities and Duties of the Job
80% Participant Care
· Provides primary medical coverage for Immanuel Pathways Participants. Completes initial, semi-annual and unscheduled assessments.
· Collaborates with Immanuel Pathways Physicians and Medical Director as indicated.
· Follows Immanuel Pathways documentation standards.
· Develops and implements appropriate plans of care, in collaboration with the IDT, to Immanuel Pathways program participants.
· Interacts with team members to meet the emergent and acute need of participants.
· Participates in discharge planning for acute and long-term placement.
· Functions as a member of the IDT. Attends and participates in IDT meetings; communicates participant changes, collaborates on care planning decisions and coordination of care delivery.
· Evaluates and treats participants during acute illness. Manages participants’ chronic illnesses and conditions.
· Manages care of participants when residing in contracted provider environments; ie; hospital, nursing home or assisted living. Provides regular visits as determined by IDT and in accordance with state and federal regulations. Communicates with contracted provider staff as needed.
· Provides preventive health maintenance for participants, including immunizations, screenings and monitoring of pertinent indicators.
· Prudently prescribes medications, referrals to medical specialists, therapies and other treatments for participants.
· Complies with state Home Health Licensure regulations for home care.
15% Quality Standards
· Works with Medical Director and Clinic Nurse Supervisor to formulate clinical policies, procedures and standards of care.
· Assists with the development of standards of care; performs on-going monitoring and evaluation of patient care practice and service delivery; provides guidance and training to staff regarding medical and quality assurance issues.
· Acts as resource during intake of new participants.
· Provides training and education regarding participant care and diagnosis to Immanuel Pathways staff as indicated.
· Serves as a resource for participant safety.
· Participates in and supports quality improvement initiatives.
5% Professional Activities
Assumes responsibility for professional activities and growth. Keeps abreast of current nursing knowledge, especially in the field of geriatrics by attending professional seminars and conferences.
· Participates in team meetings, staff meetings and monthly in service meetings.
· Perform other duties as required or requested
- Current Certification as a Nurse Practitioner, in good standing, with prescriptive authority in the respective state in which he/she is employed, is required.
- RN license in the respective state in which he/she is employed is required.
- Two (2) years treating patients in a hospital, skilled care, or other health related entity is preferred.
- One (1) year of management experience, preferably in a geriatric care setting preferred.
- One (1) year of experience working with the frail or elderly is required.
- Must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
- Must have a valid driver’s license, proof of insurance and have means of reliable transportation.
- Ability to legally practice in the respective state in which he/she is employed (NE/IA), if the Nurse Practitioner has not completed 2000 hours, will work under a collaborative agreement with Medical Director until the hours requirement has be reached.
- Basic Life Support (BLS).
KSA- Knowledge Skills and Abilities-
- Knowledge of current concepts, theories and practices related to home and community-based care for the elderly and disabled adults.
- Knowledge of health care delivery and financing systems, including Medicaid, Medicare, waiver programs, prospective and systems with a monetary cap, public health programs and Health Maintenance Organization (HMO)/Managed Care.
- Knowledge of the PACE regulations.
- Knowledge of physical, mental and social needs of frail older adults.
- Skilled in effective oral and written communication.
- Skilled in organizing time, priorities, and duties.
- Ability to lead and work within the interdisciplinary setting.
- Ability to supervise medical staff effectively.
- Ability to chart via Electronic Health Records.
- Proven experience and basic computer proficiency (internet, email, Microsoft Office).
- Ability to manage changing priorities per needs of the PACE program and the agency.
- Ability to effectively and efficiently plan, prioritize and follow-up on delegated responsibilities.
- Ability to foster collaborative working relationships.