GENERAL JOB SUMMARY

An exempt clinical position where the nurse practitioner (NP) is responsible for providing direct patient care. The NP participates as a leader of the skilled nursing facility (SNF) care team. Visits managed care and fee-for-service patients at skilled and long-term levels of care in designated SNFs facilities. Provides appropriate evidence-based geriatric medicine. Coordinates care with hospitalists, primary care physicians and care managers. Makes home visits as directed by the medical staff to meet patient needs and provide continuity of care.

ESSENTIAL JOB FUNCTIONS

• Maintains privileges in multiple Nursing Homes as directed by ACA
• Maintains license and malpractice insurance
• Consults supervising attending as needed
• Documents patient visits electronically at least 90% of the time
• Participates in documentation and other quality improvement programs
• Available via phone weekdays 8am- 7pm and when on call.
• Will reviews, approves, and modifies admission orders
• Creates a detailed admit note for each admission within 24 hours of patient admission to SNF, including medication reconciliation
• Initiates/documents Advanced Directives
• Determines if Health Care Proxy status is correct and invoke if appropriate
• On weekends, takes call for admissions and see new patients within 24 hours of admission on a rotating basis with other practitioners in the program.

Daily Visits

• Initiates and review orders, including medications, on a daily basis
• Reviews labs, radiology reports, and consults on all patients
• Talks to and examines each assigned skilled-level patient on daily rounds Monday through Friday
• Writes at least one daily progress note for each skilled patient
• Assess patient’s medical stability daily. Consults/coordinates with specialists as needed
• Addresses acute mental status changes via non-pharmacologic or pharmacologic measures, consultation or transfer
• Coordinates/assess rehab progress on a daily basis
• Discusses concerns with the patient, family, rehab, and case management. Educates patient and family members regarding acute and chronic illness management
• Attends family meetings as necessary
• Assists PCP’s that participate in SNF management
• Informs attending and/or ACA medical director of significant changes in medical condition
• Participates in weekly utilization meetings, collaborating with the SNF care team and ACA care managers
• Coordinates with PCP’s, Hospitalists, ACA Medical Directors and Case Managers
• Performs home visits on selected patients
• Addresses /coordinates any legal issues.

Discharge

• Develops a discharge plan utilizing input from case management and rehab. Identify barriers to discharge
• Creates a detailed discharge summary for each admission on all patients, including medication reconciliation, and sends to the PCP at the time of SNF discharge
• Ensures that patients have all appropriate drug and DME prescriptions at discharge
• Coordinates visits with the PCP post-discharge
• Discharges summary to be sent to the PCP at discharge
• Updates all patients in Care Screen™ before discharge
• Coordinates transition from skilled to long term placement.

Long-Term Care

• Assists case management in the evaluation of selected long term patients
• Follows “new” long term patients every 30 days
• Assists the attending physician with management for complex long-term patients

Qualifications

EDUCATION AND EXPERIENCE

• License to practice as a Registered Nurse and a certificate to practice as a Nurse Practitioner issued by the State Board of Registered Nursing.
• Geriatrics specialty certification preferred
• Minimum of three years of clinical nursing experience preferred, including work in a skilled nursing facility.
  20 days PTO,Health insurance, 401 k %2,Malpractice insurance.