Advanced Practice Provider - Pre/Post Surgical Optimization

The APP will join a multidisciplinary team dedicated to provision of innovative, patient-centered care as part of the CMS Transforming Episode Accountability Model (TEAM). This is a mandatory, episode-based, alternative payment model, in which Mass General Brigham will coordinate optimal care for traditional Medicare patients undergoing one of five specified surgical procedures and assume responsibility for the cost and quality of care from surgery through the first 30 days after the patient leaves the hospital. This model aims to improve the patient experience preoperatively, through surgery and recovery. This will be done by supporting the coordination and transition of care between providers and promoting a successful recovery that can reduce unnecessary post-acute care utilization and readmissions. This role is designed to proactively assess and support these patients through the full journey of the surgical episode (pre-surgery, in-facility surgery, post-surgery). The APP is responsible for medium- and high-risk pre-operative optimization and provides direct patient care both in-person and virtually. They will work closely with the multidisciplinary team to support patient optimization throughout the course of the episode. The APP also conducts risk capture and risk assessment, as well as closure of quality care gaps.Key Responsibilities: -Seek and maintain personal knowledge regarding perioperative optimization and associated problems to provide accurate resource information to patients-Maintain clinical competency, professional skills, and knowledge through experiences and formal continuing education programs and independent learning activities-Responsible for maintenance of all certifications/licensures required to fulfill duties of the position.-Willingness to collaborate with hospital colleagues and outside healthcare resources are essential-Foster communication between TEAM program staff and other health care team members-Participates in the assessment, development, implementation, and evaluation of quality improvement programs, standards of practice, and policies and procedures.-Fulfill duties to ensure seamless patient care as requested by medical director -Other Administrative Duties: as necessitated by program development and at the direction of leadership.Clinical Care-Provide both virtual and in-person direct patient care and education to TEAM patients-Provide support for all clinical needs of the multidisciplinary TEAM program team-Conduct comprehensive pre-operative geriatric assessments and pre-op optimization screen related to mobility, frailty and support at home-Place lab, and DME orders as indicated for TEAM pathways-Enter referrals for imaging as indicated for TEAM pathways-Enter referral to specialists as indicated for TEAM pathways-Document assessment data, orders, interventions, results and evaluations within the patient's medical record per established standards-Documentation is consistently complete, accurate, timely and legible in accordance with departmental policies and procedures-Drive early patient engagement to support safe discharge Care Coordination and Escalation-Provide clinical oversight of day-to-day team functions (including refinement of protocols, procedures and policies)-Serve as escalation pathway for CMS TEAM coordinators and PT Navigators-Collaborate with local surgical or inpatient teams as indicated-Assist in development and optimization of care pathways, perform PDSA and other process improvement tools Intra-visit and Post-operative Patient Care and Support-Provide information, education, and support to patients and families; include them in planning discussions, with a focus on discharge home-Respond to ongoing patient questions-Manage additional referrals and pre-op optimization needs-Conduct follow-up engagement as indicated-Elicit goals and values from patients and families to better guide them in care plans-Answers telephone calls/messages from patients, family members and clinical staff Documentation and Risk Capture-Complete review and documentation of patient conditions in alignment with PHSO risk capture team-Use standardized tools for risk/ discharge destination-Bill for activities via required billing pathway-Compliance with MGB billing standards

What You'll Bring

Qualifications:

- Advanced Practice Registered Nurse (APRN-NP) or Physician Assistant (PA) licensure required

- More than 2 years of licensed experience required.

- Experience in perioperative medicine and/or geriatrics preferred.

Additional Knowledge, Skills and Abilities:

- Skilled in taking medical histories to assess medical condition and interpret findings.
- Ability to maintain quality control standards.
- Ability to react calmly and effectively in emergency situations.
- Ability to interpret, adapt and apply guidelines and procedures.
- Ability to communicate clearly and establish/maintain effective working relationships with patients, medical staff and the public.

- BLS required (or secured within the first 3 months of employment)

al issues efficiently and effectively with minimal supervision

Schedule and Work Model

- Full time, Monday through Friday, standard business hours.

- This will be a hybrid role starting with a minimum of 3 days in-person per week at on-site.

- Anticipated Schedule:

• Monday and Friday on-site at Mass General Hospital.

• Tuesday WAH administrative day / every other Tuesday on-site at Assembly Row in Somerville, MA.

• Wednesday WAH / virtual visits.

• Thursday on-site at Newton Wellesley Hospital.

Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.

Required

Preferred

Job Industries

• Other