Sr Direct Care Practitioner - Boston, Bilingual preferred but not required

Who We Are

Point
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Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point
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Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are.

We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point
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Health.

Under the direction of a Senior Products Manager, the Sr Direct Care Nurse Practitioner, as an advanced practice nurse (APN) in the Post-Acute and Long-Term Care Program, provides both primary and post-acute care and direct patient management to Senior Products members in designated facilities where we have established collaborative physician relationships. The SNF (skilled nursing facility) rounder will provide primary health care management to a long-term and custodial population with a focus on best practice approaches for the geriatric population as well as follow an identified subset of members who require post-acute management following an acute period of illness.

The APN should be familiar with primary and preventative care approaches of the older adult with additional comfort in pharmacologic and end of life principles specific to this population. This oversight also includes annual wellness visits in facilities for eligible members.

The APN will apply advanced practice skills to evaluate the older adult patient, provide medical management, and assess the patient’s progress toward identified goals to achieve the best possible clinical outcome along the health and illness continuum. This will be done in collaboration with all key stakeholders including collaborating physicians with whom the APN will build and support transparent and productive relationships.

Key Responsibilities/Duties – what you will be doing (top five):

• POST ACUTE CARE
  • Performs comprehensive clinical exam and assessment upon admission
  • Meets with facility staff and identifies the goal of the SNF stay
  • Formulates discharge plan through discussion with multidisciplinary team with a focus on attainable goals and identified barriers
  • Assess the patient at each visit to determine clinical status and progress towards goals
  • Collaborates and communicates with members of the care team to establish expected length of stay, goals of stay and level of care.
  • Serves as a resource for family, member, and case management teams to establish a mutually agreed upon discharge plan that is safe and attainable.
  • Works collaboratively with all community case management teams and supports to optimize high risk discharge planning and care coordination
  • Serves as a constant resource for the family and member
  • Establishes collaborative relationships with supervising and collaborating physician groups and determines communication preferences between NP and receiving MD.
• LONG TERM CARE
  • ANP will provide primary care to long term care population in designated facilities where applicable
  • Expected to see monthly as well as when there is a change in status with a focus on treat in place conditions
  • Serve as a resource of the families, members, and staff
  • Experienced and skilled with end of life and goals of care discussions through care continuum as well as competent with Molst form completion and counseling
• CHA (COMPREHENSIVE HEALTH ASSESSMENTS)
  • Performs annual comprehensive exams on all eligible members assigned in applicable facilities and geographies
  • Knowledgeable with regards to risk adjustment coding and apply these concepts appropriately
  • Facilitating clarification of…