Community Based Nurse Practitioner Baltimore

AbsoluteCARE Medical Center & Pharmacy; Baltimore (MD); On-site; USD 110,000 - 150,000; Full time

Job summary

AbsoluteCARE Medical Center & Pharmacy seeks a Community-Based Clinician to deliver primary and urgent care in patients' homes, focusing on transitions of care after hospital discharge.

You will manage a small panel of homebound members, resolve acute home or clinic issues, and coordinate with the Core Clinical Team to ensure seamless care. ACLS certified clinicians with EMR proficiency are preferred.

Qualifications

• Community-based home visit role requiring direct patient contact.
• ACLS certification required.
• Ability to manage multiple priorities in a fast-paced environment.
• Experience analyzing and leveraging clinical reporting data.
• Proficient with Electronic Medical Records and Microsoft Office.

Responsibilities

• Provide community-based medical and care-coordination services for recent hospital discharges.
• Manage a small panel of homebound patients requiring primary care.
• Resolve acute issues in the home or clinic or direct to the most appropriate care setting.
• Coordinate with PCP, Care Manager, SW and ICT for follow-up and problem solving.
• Implement transitional care protocols and educate patients on adherence and self-management.

Skills

Patient-centered care

Time management

Communication

Adaptability

Education

Certified Registered Advanced Practice Provider (Adult Medicine) with Acute Care experience

Tools

Electronic Medical Records

Microsoft Office

Job description

The Community-based Clinician provides needed primary and urgent care in the home. Great focus on managing transitions of care, especially in the important and delicate time after hospital discharge. This position adds to a member's current care, collaborating with their current care providers. The role is immensely satisfying, as you practice enhanced primary care and have the benefit of expert care management. Seeing members in the home allows you great insight into the social factors that affect their care. This is a tremendous opportunity to impact the care of vulnerable patients.

Duties and Responsibilities

Provide community-based medical and care-coordination services for recent hospital discharges. Manage a small panel of homebound members who require primary care. Resolve acute issue in the home and clinic or by directing member to most effective and efficient solutions.

• Acute onset of a new illness.
• Evaluation of acute exacerbations of chronic conditions.
• Shortness of breath without chest pain, change in mental status or new onset hypoxia.
• CHF exacerbations
• Asthma/COPD exacerbations
• Bronchitis/pneumonia
• Hyperglycemia
• Elevated blood pressure
• Evaluation and treatment of a variety of infections
• New or worsening aches or pains, wounds, depression and/or anxiety.
• Members we know will go to the ER if not seen today.

Ensure coordination of care to include:

Timely and accurate completion of chart documents.

• Work with Treatment and Triage Nurse to address sick calls and visits requiring Provider management.
• Receive input from the Core Clinical Team (PCP, Care Manager or SW) to define visit goals.
• Communicate important post visit follow up information to Core Clinical Team.
• Collaborate with Integrated Care Team (ICT) members (behavioral health, nutrition, health education) for problem solving and coordination of care.
• Identify and refer to specialty programs when instability or crisis occurs such as: abuse/neglect, interpersonal violence, significant and complex housing, and food insecurity.
• Implement transitional care protocols as part of warm hand offs between internal and external care providers.
• Help patients identify barriers to meeting health and life goals and connect patients with resources to navigate barriers.
• Adjust care plan following guidelines for evidenced based chronic disease management.
• Educate and coach for medication adherence and chronic disease self-management skill development.
• Monitor members at risk of being lost to care and implement interventions to prevent loss.

Education & Experience Requirements:

• This is a Community Based position must be willing to do home visits
• Certified Registered Advance Practice Provider in a field of Adult Medicine with Acute Care experience.
• ACLS certified.
• Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care.
• Ability to meet deadlines and manage multiple priorities.
• Effectively adapt and respond to a complex, fast-paced, and results-oriented environment.
• Success using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.
• Excellent computer skills, including knowledge of Microsoft Office.
• Patient-centered focus.
• Familiar with care transitions, strategies for reducing readmissions and chronic condition management interventions.

Preferred qualifications:

• Experience in a Patient Center Medical Home.

• Experience working with high risk and medically complex patients with multiple comorbidities.