Advanced Practice Clinician

• Manages and provides the full scope of advanced nursing practice for targeted patient populations, which may include short-term treatment of members at the point of care. Evaluates patient responses to therapy/interventions. Ensures revision of the inter-professional plan of care as necessary to achieve quality outcomes.

• Serves as the clinical authority on individualized care teams and leads rounds and interdisciplinary care team meetings.

• Manages and provides comprehensive, advanced nursing care, including post-discharge aftercare visits, annual comprehensive assessment visits, palliative care-care management program onboarding, and change in condition assessment visits (including physical examination, comprehensive history, screening for physical and/or psychological conditions, and point of care testing). Urgent interventions (i.e., escalations for the Care Teams, RPM, and the 24/7 Line), pharmacological and non-pharmacological interventions, ordering treatments and DME, preventative health maintenance activities, care management, referrals, discharge planning, counseling, and patient education. Establishes a treatment plan based on clinical findings and determines when further evaluation by the collaborating physician, specialist, or emergency care is warranted.

• Collaborates with patients, families, primary care physicians and other team members to provide assessment and care planning. Assesses, plans, and provides intensive and continuous care management across client settings.

• Manages and provides clinical services in compliance with standards of Patient-Centered Medical Home standards, meaningful use of medical record data, HEDIS and QARR quality of care measurements.

• Manages inter-professional team efforts regarding the medical, nursing, therapy and ancillary care provided to patients to ensure quality outcomes are achieved.

• Participates in on call coverage schedule to ensure 24/7 access to practice clinicians.

• Assesses, educates, and improves client and caregiver knowledge of chronic disease, self-care management, and identification of changes in health status, including appropriate responses and actions through individualized education and inter-professional interventions.

• Observes and analyzes team performance patterns related to population under care and assists in developing interventions to improve team performance. Provides remedial support and guidance to interdisciplinary team members to address implementation/evaluation of plans that maintain/increase customer experience with care, cost-efficiency, and quality care compliance with regulatory standards.

• Communicates with internal and external care partners regarding the needs of the patient or population to ensure interventions occur in a timely and appropriate manner. Intervenes as needed when the care plan is not executed and remediates the situation to prevent reoccurrence.

• Performs procedures as outlined in collaborative practice agreement and as privileged by the Credentialing Committee.

• Manages quality of medical record documentation and submits billing information in accordance with Professional Corporation policy.

• Provides care in one or more care settings based on the clinical requirements: virtually, telephonically or travels to patients’ homes and/or other facilities with varying environments (e.g., elevated buildings, walk-ups, care facilities, single/multiple family homes, presence of pets, etc.) using approved transportation options.

• Upon request, performs peer reviews of work performance, including quality of care, clinical documentation, coding and billing practices, communication skills, and population surveillance. 

• May participate in the VNS Health Medical Care at Home Quality and Professional Advisory Committee and any associated workgroups related to development of evidence based clinical models of care, peer education and training, quality improvement, medical record configuration and reporting, maximizing the use of clinical decision support systems. 

• May act as a preceptor for student Nurse Practitioners, providing excellent role modeling of community-based primary care practice. 

• Assumes responsibility for continued professional growth, and maintains professional certification and licensure.

• For Psychiatric Nurse Practitioners only:

• Conducts psychosocial assessments of interventions patients and develops treatment recommendations. Determines whether further evaluation by a collaborating psychiatrist is needed.

• Provides the following services to patients: advocacy, psychoeducation, psychopharmacology, cognitive/behavioral interventions, monitoring of mental status, emotional support, brief psychotherapy and family-based interventions.

• Supports and educates VNS Health staff and caregivers to enable them to better care for patients with psychiatric, cognitive, and/or behavioral challenges.

• Consults with a collaborating psychiatrist as necessary to develop psychiatric evaluation and treatment plans.

• Consults with the referrer on assessment, recommendations, and updates on treatment progress.

• Follows treatment plans, revising and updating them as necessary, makes appropriate referrals for additional mental health services and provides crisis intervention as required. 

• Participates in interdisciplinary team meetings, case conferences and clinical supervision; attends in-service education programs.

• Participates in special projects and performs other duties as assigned.