Participates in initiatives designed to promote quality of life and optimal health of older persons in the community by integrating concepts of prevention, health maintenance, rehabilitation, and palliation in a culturally appropriate manner. Provides clinical leadership to promote compliance with quality, cost measures,and standards of care. Provides ongoing clinical care, education and mentoring to staff/patient/family.Collaborates with management in the evaluation of clinical outcomes data and analysis of practice patterns.Promotes organizational responses that meet the needs of the population. Manages service delivery of inter-professional and para-professional team members working on an individual case or population of cases. Provides advanced nursing clinical care for patients in accordance with current State and Federal rules and regulations for nurse practitioner scope of practice and national standards of care. Works under general supervision.
Conducts in home,virtual, and/or telephonic encounters (initial or follow up) to identified clients in accordance with regulatory and practice guidelines. Manages and provides comprehensive advanced nursing care including physical examination, comprehensive history, screening for physical and/or psychological conditions, emergent interventions, 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. Determines when further evaluation by collaborating physician, specialist or emergency care is warranted.
Analyzes data on individual and stratified populations of patients with complex needs; assesses conditions such as clinical needs, patient satisfaction, quality of life, and cost-effectiveness. Determines strategies for prevention of complications of the above through risk stratification tools, protocols, and ongoing collaboration with physician and multidisciplinary team.
Manages and provides clinical services in compliance with standards of Patient Centered Medical Home, meaningful use of medical record data, HEDIS and QARR quality of care measurements.
Participates in on call coverage schedule to ensure 24/7 access to practice clinicians.