Nurse Practitioner - Longitudinal Care

The Longitudinal Care Nurse Practitioner is responsible for providing health care to patients enrolled in the CareSight Program in their home. The Provider leads a care team that consists of Registered Nurses and Community Health Workers (CHW) and works closely with the patients primary care physician.

Position Essential Functions:

• Delivers cost-effective, high-quality care to assigned CareSight patients
• Completes comprehensive history and physical examination on all enrolled patients in an in-home visit
• Collaborates with RNs, CHWs and patient to determine patients risk of adverse health outcomes
• Adjusts the patients risk level as appropriate based on assessments
• Completes proactive, in-home visits on all intensive level patients at least monthly
• Completes proactive, in-home visits on all core level patients quarterly
• Completes unplanned, urgent, and/or emergent in-home or telehealth visits as needed to meet patient needs
• Adjusts visit frequency and schedule based upon patient needs
• Responds to calls from the patient, caregiver, CareSight RNs, etc.
• Addresses Advance Care Planning proactively; identifies surrogate decision maker (MPOA, Health Proxy, etc)
• Manages patients medical care as appropriate including:
  
  
  
  • Orders and monitors of diagnostics including laboratory studies, radiological studies, etc.
  • Refers to appropriate specialists or community services, i.e. Home Health, DME, community resources
  • Addresses recommended preventive and quality measures; acts to close potential care gaps
  • Monitors chronic conditions to minimize exacerbations or treat (in place if clinically appropriate)
  • Identifies, assesses, diagnoses, treats acute changes of condition (in place if clinically appropriate)
  • Manages medication therapy effectively:
    
    
    
    • Reviews and reconciles medications each visit
    • Avoids high-risk medications
    • Prescribes medication, adjusts dosages, discontinues medications as appropriate in collaboration with PCP
    • Simplifies medication regimen for improved adherence
    
    
    
    
  • Administers selected medications in the home (if clinically safe to do so)
  
  
  
  
• Collaborates with RNs and CHWs in the development of an integrated care plan that identifies key patient problems, goals of care, barriers to meeting goals, interventions, activation level, and patient self-management activities
• Communicates effectively with entire care team including the patients community primary care provider
• Provides effective patient education using the Teach Back technique
• Documents all patient encounters (in-home, telehealth, and telephonic) per documentation standards
• Participates in clinical case conferences as required
• Participates in on-call coverage for patient care
• Travel required
• Performs miscellaneous job-related duties as assigned

Job Qualifications:

• Holds active, unencumbered license in New York state
• Credentialed in adult, family, or geriatric care preferred
• Board Certified AANP or AANC
• Has active DEA license
• Current CPR/BLS certification
• Experience in care of adult, chronically ill patients
• Two or more years of practice experience preferred
• Drivers license without restrictions and good driving record
• Working knowledge of computers and ability to document effectively and efficiently in an electronic system
• Excellent communication skills
• Able to function independently
• Enjoys working in a collaborative environment

Emcara Health is an equal opportunity/equal access employer fully committed to achieving a diverse workforce.