The Community Nurse Practitioner Care Supervisor (CNPCS) will work in collaboration with contracted community primary care physicians (CPCP)to ensure proper oversight and coordination of participant care with the Interdisciplinary Team. The CNPCS will work with the community physician to coordinate and support the participant’s functional, clinical, and psychosocial needs, with an emphasis on independence and wellness. This role will work as the liaison between the participant, the community physician, and plan staff to develop and implement the plan of care including person-center goal development, communicating changes in participant condition and facilitating primary care preventative services.
Each NP will be assigned a panel of participants that are associated with Community Primary Care Physicians whose offices are located in a defined geography . The Community NP will be responsible for forging a collaborative working relationship with each of these CPCPs and their respective staff to ensure that the practices are familiar with the PACE model of care and its special requirements and assure adherence to the individual plan of care and optimal outcomes
This role will incorporate several critical functions including but not limited to:
- Conducting in person visits to the CPCP as needed to cultivate appropriate lines of communication around care coordination and care delivery for each participant. This will include providing a clear plan of communication and engagement including the delineation of the full range of clinical and social supports offered by CenterLight (CL) in serving frail elderly participants who reside in community settings.
- Defining protocols and expectations regarding timely provision of required clinical documentation including in-office assessments specialist evaluations diagnostic reports including labs, imaging studies, and PCPC notes.
- At a minimum, performing routine quarterly clinical assessments on all assigned participants which reflects an understanding of the complexity and multiple co morbidities of the frail and/or elderly. For participants with higher levels of risk, these assessments will be performed more frequently to appropriately address his/her level of need as described below.
- Assesses and manages participants with acute change in condition in a timely manner.
- Assesses participants upon return from the hospital within twenty-four (24) hours or as soon as practical but no later than 72 hours. This includes the reconciliation of medications and treatment plans and coordination with participant’s CPDCP and IDT members to ensure timely transition of care follow up visits.
- Works with Participant’s CPCP to ensure that participants receive timely an appropriate visit consistent with their needs and plan of care.
- Reviews patient’s past medical history at least every 6 months and formulates a comprehensive and complete diagnostic list of current and past medical conditions using clinical knowledge and judgement and the findings of his/her assessment. The NP is responsible for ensuring that all such complete, accurate and specific diagnosis codes will be documented in CL’s clinical platform and as encounter data as required.
- Reviews Participant’s current symptoms, exacerbation of problems that were previously controlled and identify active diagnoses and chronic problems or conditions to be used in Care Management and active medical management of treatment and designed interventions.
- Communicates findings of assessments to inform Participant’s PCP of potential gaps in care and coordinate with CPCP on a care plan that will address these gaps.
- Attends and participates in CL’s Interdisciplinary team (IDT) meetings and represent CPCP when he/she is unavailable to attend or delegates the role to the NP.
- Communicates with CL’s IDT team or other CL Plan designees in accordance with CL’s policies and procedures.
- Educates participants and their families and CL staff on such topics as disease processes, medication adherence and self- management promotion.
- Complies with all HIPPA regulations and maintains security of Protected Health Information.
- As any other PACE provider will conduct field visits to CPCP offices or home visits as needed.
- Act as the direct supervisor of the care plan formulation and the proper delivery of it by each discipline for the community PCP participants, The care plan must be tailored to the needs of the individual, all interventions and outcomes most be followed and supervised by the practitioner.
- Supervises the home care services that the HRN arrange/provides for the community PCP participants.
- Responsible to ensure that the care coordinated by the HRN is appropriate and deemed for the patient needs, including but not limited to: scheduling, plan of care development and overseeing the clinical outcomes and participant satisfaction of the HRN’s services.
- Act as the direct supervisor of the care plan for the community PCP participants.
- In addition to supporting his/her community-based panel, the incumbent will also provide emergency coverage for CL’s PACE center primary care providers as needed
- On call rotation will be expected as part of the job duties.
- Performs other duties as assigned.
Education: Graduated from a nurse practitioner education program acceptable to NYSED or be certified as a nurse practitioner by a national certifying organization acceptable to NYSED.
- Minimum of two years in clinical nursing practice in home care, care management or related field required.
- Effective oral and written communication and interpersonal skills required.
- High level analytical and research skills.
- Ability to manage multiple projects and meet project deadlines.
- Basic Computer Skills in Microsoft office.
- Licensed to practice as Nurse Practitioner in NY