Commonwealth Care Alliance

Community Advanced Practice Clinician (NP/PA)

  • Commonwealth Care Alliance
  • Boston, MA 02129
  • 22 days ago

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Job Description

Performs both urgent and routine visits on members to evaluate condition and add to the plan of care • Orders appropriate medical testing to aid in the diagnosis and medical management of acute and chronic diseases • Leverages CCA clinical resources (InstED) to avoid emergency room visits and inpatient admissions.

• Evaluate test results, appropriately treat member illness and communication/collaborate plan with PCP • Facilitates and/or delivers preventative care to members according the guidelines deemed appropriate by CCA • Engages in appropriate clinical collaboration with clinical experts, including the member’s PCP, CCA Medical Directors, and other CCA Advanced Practice Clinicians.

Clinical Leadership.

Guidelines may vary based on the individual make-up of the member and is based on age, comorbidities, etc.

• If appropriate, provide medical and psychiatric bridge prescribing abilities for members in transition between providers • Evaluate member’s HEDIS measure needs, write orders as appropriate to manage these gaps and follow up with PCP on results Assist with Advanced Care Planning, including establishing goals of care with members and obtaining MOLST forms • Provides limited regularly scheduled follow up visits for the management of chronic disease.

Visits are inclusive of a history of present illness, review of systems, physical exam, ordering of appropriate studies and tests, identification of a definitive diagnosis, adjustment or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation.

• In order to decrease risk of readmission, performs post discharge visits on member members within 48-hours of discharge from either an acute care facility or a skilled nursing facility; performs detailed medication reconciliation, adjust medications as indicated, and ensure appropriate LTSS are in place, • Liaises with CCA Care Partner and community based PCPs/ Specialists, as needed • Provides Intermittent Skilled Care as necessary (e.g., wound care,) • Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly • Complete MDS assessments • Complete Annual/Geriatric Comprehensive Assessments to ensure all members have had an annual physical exam • Complete medication reconciliation with every member visit.

Attend weekly Interprofessional Team Meetings • Participate in Root Cause Analysis (RCA) as appropriate • At each visit, provide member education, assess vital signs and complete medication reconciliation.

• Formulating an action/ treatment plan based on scientific rationale, evidence –based standards of care and practice guidelines that demonstrate critical thinking, diagnostic reasoning and knowledge of the pathophysiology of acute and chronic disease and conditions • Monitoring the response to the action / treatment plan with appropriate and timely follow up, evaluation and initiating necessary changes in the action / treatment plan.

adhering to CCA policies and procedures • Adjusts the member centered plan of care as necessary based on a significant change in condition.

A change in condition is an event (hospitalization, acute illness, etc.) which results in either a short or long term change in need (examples include adding in Palliative care, increasing personal care hours short term post hospitalization, or purchasing high cost durable medical equipment for a non-reversible functional change) • Utilizing and depending on CCA internal resources, ensures that the plan of care is implemented in a timely manner.

• Collaborate in evaluating member’s service plan and authorization to inform Telephonic Care Partner and allow for appropriate service utilization for members • Ability to document clearly and comprehensively.

In condition is an event (hospitalization, acute illness, etc.) which results in either a short or long term change in need (examples include adding in Palliative care, increasing personal care hours short term post hospitalization, or purchasing high cost durable medical equipment for a non-reversible functional change) Utilizing and depending on CCA internal resources, ensures that the plan of care is implemented in a timely manner.

Seconday Responsibilities • Collaborate in evaluating member’s service plan and authorization to inform Telephonic Care Partner and allow for appropriate service utilization for members • Participates in “weekend schedule” rotation which includes working Saturday, Sunday, and 2 weekdays.

Estimated at 6-8 times per year • Ability to document clearly and comprehensively.

Acts as a mentor to other team members to help promote/foster accountability, reliability, and independence among the other team members • Provides consultation and support to CCA team • Participates in Team Case Review • Maintains appropriate written and oral communication on a timely basis completing documentation within 24 hours of activity, and returning non-urgent calls within 48 hours • Conducts educational and training activities that promote appropriate, safe, effective patient care • Actively participates in the evaluation of own performance and progress • Participates in activities and education to maintain and advance competency • Participates in CCA quality improvement efforts • Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects • Participates in committees and workgroups that promote clinical excellence and help to advance CCAs mission and business objectives • Maintains confidentiality of patient and employee information • Complies with organization’s policy and procedures • Advocates for members in a culturally competent manner.

• Seeks maximum member and family participation to promote independence Must be willing and able to travel to member’s homes in addition to working in an office environment occasionally Must be willing and able to attend meetings at the at the office, with other travel possible Valid driver’s license with no restrictions.

Ability to be active and mobile across Massachusetts

Master’s Degree in Nursing, Doctor of Nursing Practice or a degree in Physician Assistant Studies 3-5 years meaningful clinical experience in primary care or care management, including: • 5+ years’ experience as Registered Nurse or EMT-P in a high touch clinical environment or home care; OR • 3+ years’ experience as an NP or PA in primary care or care management; at least • 2+ years caring for patients/ members with complex medical, behavioral health, and social needs • Board Certified NP or Physician Assistant with licensure in good standing in the Commonwealth of Massachusetts.

• Will be required to pass CCA’s credentialing process.

• Current Mass Controlled Substances License required • Current DEA Controlled Substances License required • Current CPR or Basic Life Support (BLS) Certification Required: • Is able to conduct and document a Pain Assessment • Is able to use SBAR Communication • Is able to conduct and document Home Safety Evaluation • Is able to provide Wound Care (simple & complex) • Is able to utilize an Electronic Medical Record and Care Management Platform • Is able to use on-line training platforms • Demonstrates an understanding of the Model of Care • Demonstrates an understanding of the benefits of each program • Is able to review welcome packets and obtain consent forms and attach them to EMR • Demonstrates an understanding of when an updated MDS is needed • Is able to complete a comprehensive MDS Assessment • Is able to complete and update a Care Plan that meets CCA requirements • Demonstrates an understanding of LTSS • Demonstrates an understanding of how to use CDSTs when ordering services • Is able to create referrals and authorize services within appropriate time frames • Is able to complete and lock all required notes and telephone encounters within 48 hours • Participates in case discussions • Able to lead a family/team meeting for the purposes of discharge planning • Returns all non-urgent calls within 2 days and urgent calls as required • Performs a post-discharge visit within 48 hours of discharge • Obtains/documents a comprehensive history • Demonstrates knowledge and ability to use screening/ assessment tools to Fall risk assessment o Mini cog assessment o Nutritional assessment o PHQ 2 o PHQ 9 o Able to perform venipuncture • Demonstrates ability of how to locate current guidelines for recommended screening tests and immunizations • Is able to conduct and document an Annual Comprehensive Exam • Is able to formulate Diagnosis/ Differential Diagnosis • Demonstrates an ability to prescribe medications • Demonstrates an ability to order diagnostic testing

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

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