EverCare Nurse Practitioner

Job Summary

Assumes responsibility and accountability as the primary clinician for a panel of geriatric patients within the Ever Care practice. The Ever Care Nurse Practitioner provides the majority of bedside and longitudinal primary care, including comprehensive assessment, diagnosis, treatment, chronic disease management, and care coordination for medically complex older adults across office, home, and facility settings. Services are provided under a collaborative practice agreement with the physicians of the practice.

The NP provides clinical direction to the Ever Care Registered Nurses delivering chronic care management services and is accountable, together with the interdisciplinary team, for the quality, patient experience, utilization, and total cost of care outcomes that drive the practice’s performance in the Accountable Care Organization (ACO) and other value-based arrangements. Participates in the on-call schedule per on-call policy.

• Serves as the primary clinician for an assigned panel of geriatric patients, providing longitudinal primary care in office, home, assisted living, and skilled nursing settings as assigned.
• Completes and documents accurate, comprehensive histories and physical examinations; provides diagnosis and treatment of acute and chronic conditions, including ordering and interpreting diagnostic tests and prescribing medications and treatments according to the collaborative practice agreement and NP scope of practice laws, as approved by the Medical Director.
• Performs comprehensive geriatric assessments addressing chronic disease burden, functional status, cognition, mobility and fall risk, sensory impairment, nutrition, continence, mood, polypharmacy, caregiver capacity, and social determinants of health.
• Conducts Annual Wellness Visits (AWVs), Initial Preventive Physical Exams (IPPEs), and comprehensive visits that support accurate and complete documentation of all active diagnoses to the highest level of specificity, supporting risk adjustment data integrity and appropriate care planning.
• Performs proactive medication management for older adults, including deprescribing of potentially inappropriate medications, simplification of regimens, and medication reconciliation at every encounter and following all transitions of care.
• Manages acute changes in condition with a treat-in-place approach whenever clinically appropriate, including urgent visits, telehealth assessment, and after-hours telephone management, to prevent avoidable emergency department visits and hospitalizations.
• Leads timely post-discharge care following hospital, emergency department, and skilled nursing facility stays, including Transitional Care Management (TCM) visits within required time frames, in coordination with the Ever Care RN.
• Provides and documents advance care planning, goals-of-care, and end-of-life discussions with patients, families, and legal representatives; completes and maintains advance directives and POST/POLST documentation; coordinates timely referral to palliative care and hospice services when appropriate and requested.
• Establishes and updates individualized, patient-centered care plans in collaboration with the Ever Care RN, and provides clinical direction for the RN’s chronic care management activities, including reviewing escalations, co‑signing care plans as required, and prioritizing outreach for high-risk patients.

• Coordinates with internal and external members of the patient’s health care and family/caregiver teams, including specialists, hospitals, facilities, home health, behavioral health, pharmacies, and community agencies, to ensure continuity of care across all settings.
• Maintains consistent, ongoing communication with the collaborating physician regarding patient status and all aspects of care, and consults with physicians within the practice according to the collaborative practice agreement.
• Communicates with nursing home, assisted living, and other facility staff regarding goals of care and treatment plans.
• Leads and participates in interdisciplinary team (IDT) meetings,…