Geriatric Nurse Practitioner

This position works in collaborative practice with the primary care physician to provide primary care for Senior Health Partners participants.  This position plans, delivers, coordinates and evaluates medical care in collaboration with the PCP and the Care Team.  Provides clinical direction and oversight for the care received by Senior Health Partners participants in the day center as well as other settings including hospitals, nursing homes and home.  Position works with the Medical Director in the development and implementation of medical policy, protocol development, quality management, utilization management and review, and biomedical ethics.

 

Job Responsibilities:

I. Shares responsibility for medical assessments on all new Senior Health Partners participants and at least every 120 days for current enrollees in collaboration with primary care physician.

A. Conducts thorough history and physical examinations on new participants and as needed

B. Examines and treats episodic acute illnesses

C. Records periodic medical changes and performs follow-up examinations of all participants at least every three months.

II.  Collaborates with primary care physician and center nurses to coordinate all medical services and consultations in day center and participant’s home

A. Provides and coordinates 24-hour coverage of direct medical care

B. Consults and coordinates with primary care physician and routine specialists to ensure coordination of care and consistency in work toward common objectives

C. Examines participants and consults with staff on medical conditions as requested by staff

D. Monitors utilization and consults with providers regarding appropriate utilization of medical services, providing information and data as needed.

E.  Monitors participant drug regimen and coordinates with pharmacy consultant.

 

 

 

III.  Collaborates to coordinate specialty consultations, acute care hospital, and nursing facility care.

A. Serves as the liaison between Senior Health Partners and consulting physicians.  In Pre-PACE, collaborates with non-Senior Health Partners primary care physicians regarding individual care plans

B. Serves as the liaison between Senior Health Partners and the acute care hospital.

1.  Coordinate transfer to acute care hospital, including all records and telephonic discussions for a direct admission to the acute hospital or for admission through  its emergency department;

2.  Coordinate care management during the hospitalization

3.  Coordinate transfer on discharge from the acute hospital ensuring the arrangement of medical follow-up, home care service, medications and clinical monitoring..

C. Serves as the liaison between Senior Health Partners and nursing facilities for sub-acute in-patient stays.

1. Either visits nursing home patients or contacts the nursing facility at least weekly to review status and care plan

2. Reviews records and verifies implementation of care plan.  Makes changes to the care plan as needed.

3. Arranges for staff participation in care conferences and discharge planning.

4. Coordinate transfer on discharge from the nursing facility ensuring the arrangement of medical follow-up, home care service, medications and clinical monitoring.

IV.  Provides counsel, support and education to staff, participants and families

A. Participates in Morning Meeting, care planning and care conferences as appropriate

B. Provides formal and informal education as needed to support the continuous learning of staff.

C. Collaborates with Care Team in the education and support of participants and families

D. Serves as a role model and resource for nursing staff and promotes the professional development of nursing staff.

V. Participates in the quality management program to ensure the highest standards of care and continued effort toward the improvement of care delivery

A. Complies with quality plan and regulatory requirements

B. Serves on quality management committees as assigned.

C. Assists in the design and implementation of quality studies

D. Conducts assessments and gathers data to demonstrate trends and patterns for quality assessment

E.  Participates in the development of policies and protocols that reflect standards of practice and regulatory requirements

F.  Provides ethical practice and application of advanced directives

VI.  Coordinates medical care with the administrative aspects of Senior Health Partners

A. Authorizes treatment by the care team and other members of the provider network

B. Signs care plans and orders for medical care

C. Reviews medical bills as requested to verify authorization compliance

 

*Must be Bilingual - Spanish/English