Care Home Matron

Summary The Nurse Practitioner (NP) is responsible for primary care to an assigned panel of participants at PACE SEMI. They provide participant acute and chronic care management under the direction and supervision of the center Physician‑In‑Charge (PIC).
Specific Duties and Functions Chronic Disease Management:
Perform monthly quota of comprehensive annual and semi-annual assessments.
Conduct chronic care management visits every 3 months.
Update management and treatment plans for changes in chronic disease or new diagnoses.
Conferee with the Physician and other clinical team members regarding participant status changes.
Pharmacy Prescribing:
Prescribe controlled substances, Schedule3-5 medications delegated by the supervising physician.
Specialty and diagnostic referrals:
Guide referrals with staff physician guidance.
Initiate appropriate diagnostic studies (laboratory, x‑ray, other specialty procedures) with physician approval.
Interdisciplinary Collaboration:
Coordinate care with IDT, PCT, UM, and other PACE services, communicating participant changes.
Preventative Care Services, Acute Care Management, and Patient Education.
Documentation:
Document in the medical record using the “SOAP” format.
Complete notes with full assessment preferably within 24 hours but no later than 72 hours.
Facilitate coding capture of Hierarchical Chronic Conditions.
Utilization Management:
Contribute to Utilization Management Goals of Care.
Facilitate advanced directives and end‑of‑life discussions with participants and families.
Manage end‑of‑life care with support from consulting hospice services.
Location of Care: Clinic (mostly), participant home, nursing facility, and telemedicine.
After‑hours call: Participate in after‑hours on‑call medical assistance on a rotating basis via telephone triage or after‑hours home visits to participants as needed.
Participation in monthly education conferences.
Scope of Practice In accordance with Michigan law, an NP may practice independently within his/her scope of practice per professional license; specifically, a Nurse Practitioner may practice independently per RN licensing scope. Outside that scope, the NP must practice under the supervising physician’s scope of practice. Supervision is provided by immediate, on‑site supervision by the PACE SEMI physician or telephone consultation with a PACE SEMI physician who is not on the premises.
Professional Requirements Three (3) to five (5) years of progressively responsible experience as an RN in a clinical setting with expertise in geriatrics is preferred, through education, experience, and credentials. Must have at least one (1) year of experience with a frail or elderly population.
Maintain a current Michigan NP License in good standing and fulfill CME requirements.
Comply with PACE guidelines for TB screenings, infection control, BLS, and mandatory in‑service requirements.
Act as a role model for professional nursing practice among peers, support and contribute to the development of nursing students and students of other health‑related disciplines, and establish and maintain interdepartmental relationships.

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