Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.
Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients . We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.
Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group.
At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.
This position provides in home medical care and management to home based Landmark members with documented or suspected behavioral health conditions. Landmark recognizes that Behavioral Health dramatically can impact Medical Health and this position collaborates with the Chief Behavioral Health Officer, Associate Director of Behavioral Health, Regional Medical Director, PCP/Psychiatrist, interdisciplinary team and other health professionals, to develop comprehensive member goals of care to fully integrate medical and behavioral health care for optimal outcomes and quality of life.
- Focuses primarily on the Landmark population with identified or suspected behavioral / mental health conditions and “adopts” these patients to add psychiatric expertise to the medical management plan and mitigate any negative impact that behavioral conditions can have on patient overall health and well-being.
- Actively participates with weekly Landmark interdisciplinary team meetings to assure behavioral health issues are considered and addressed for all high risk patients
- Psychiatric NP establishes and maintains effective relationships with members and their legal representatives, facility staff, PCPs, existing psychiatrists and other collaborating mental health providers to maximize continuity and compliance with individualized member care plan.
- Escalates and communicates any issues with Severely Mentally Ill (SMI), complex mental health patients, and any active inpatient psych admission with the Chief Behavioral Health Officer, Associate Director of Behavioral Health lr local designee.
- Practices in accordance with the respective state laws and regulations governing the practice of advanced practice nursing or physician assistants.
- Understands and complies with long-term care policies and procedures, including those that regulate nursing facilities and assisted living communities.
- Performs an initial comprehensive assessment on all newly enrolled members and at least annually thereafter. Develops a member management care plan upon enrollment and updates it as needed when changes in condition warrant or following hospitalization. Meets with members and/or their legal representatives to review newly developed or modified care plans; involves the PCP in these meetings.
- Calls and communicates directly with patient’s PCP in real time to discuss any changes of condition and potential medication changes. Plans will be collaboratively decided on with PCP, but if unable to reach and emergent situation, NP will render appropriate services and communicate changes at first available opportunity.
- Current, unrestricted State NP license
- Completion of RN accredited program
- Completion of accredited program in Psychiatric/Mental Health Nurse Practitioner (PMHNP)
- Minimum of two (2) years clinical experience, with home based care desired.
- Knowledge of CPT, ICD-9 and HCPC codes
- Knowledge of clinical standards of care.
- Awareness about UM standards, NCQA requirements, CMS guidelines, Milliman guidelines, and Medicaid/Medicare contracts and benefit systems is helpful.