SUMMARY:
The Nurse Practitioner (NP) is responsible for primary care to an assigned panel of participants at PACE SEMI. As such, they are responsible for participant acute and chronic care management under direction and supervision of the center Physician-In-Charge (PIC).
SPECIFIC DUTIES AND FUNCTIONS:
Chronic Disease Management
- Responsible for performing monthly quota of comprehensive annual and semi-annual assessments
- Chronic Care Management visits done every 3 months
- Changes in chronic disease or new diagnoses, and updating management and treatment plans accordingly
- Conferring with the Physician and other clinical team members with changes in participant status
- Pharmacy Prescribing including controlled substances, Schedule 3- Schedule 5 medications, that the supervising physician has delegated
- Specialty and diagnostic referrals with staff physician guidance
- Initiating appropriate diagnostic studies, such as laboratory, x-ray and other specialty procedures with physician approval/oversight
- Interdisciplinary Collaboration- Coordinates care with the IDT , PCT, UM, and other PACE services communicating participant changes to the interdisciplinary team
- Preventative Care Services
- Acute Care Management and Treatment
- Patient Education
- Documentation: Documents in the medical record in the “SOAP Format”, Completion of notes with full assessment preferably within 24 hours but no later than 72 hours, Facilitates Coding capture of Hierarchical Chronic Conditions
- Utilization Management - Contributes to Utilization Management
- Goals of Care: Facilitates Advanced Directives, Facilitates Goals of Care and End-of Life Discussions with participants and families: Facilitates Advanced Directives, Manages end-of-life with support of consulting hospice service.
- Location of Care: Clinic (mostly), Participants Home, Nursing Facility and Telemedicine
- After-Hours Call- May 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 Conference
SCOPE OF PRACTICE
In accordance to Michigan law, an NP may practice independently within his/her scope of practice per professional license; specifically, a Nurse Practitioner may practice independent per RN licensing scope. However, outside of that scope, he/she must practice under the supervising physician’s scope of practice per his/her delegation. Supervision of the NP provided by several methods:
- Immediate, on-site supervision by the PACE SEMI physician;
- Telephone consultation with a PACE SEMI physician who is not on the premises
PROFESSIONAL REQUIREMENTS
- Three (3) to five (5) years of progressively more responsible experience as an RN in a clinical setting with expertise substantiated in the area of geriatrics is preferred, through education, experience and credentials. Must have one (1) year of experience with a frail or elderly population.
- Maintain current Michigan NP License in good standing and fulfills CME requirements
- The nurse practitioner must comply with PACE guidelines for TB screenings, infection control, BLS and mandatory in-service requirements.
- The nurse practitioner acts as a role model for professional nursing practice among his/her peers.
- The nurse practitioner supports and contributes to the development of nursing students as well as students of other health-related disciplines.
- The ability to establish and maintain interpersonal and interdepartmental relationships.
- The ability to apply principles of teaching/learning theories in planning and implementing educational activities.
