Description

POSITION DESCRIPTION:

The Nurse Practitioner or Physician Assistant will make home visits to perform Face -to-Face assessments establishing ongoing Hospice eligibility or appropriate discharge with clinical documentation in the EMR, Home Care Home Base. Visits will be made to Hospice clients being served primarily by the Cadillac Hospice Branch but on occasion the Grayling Hospice Branch.

ENTRY REQUIREMENTS

Registered Nurse/MSN and board certification as an adult/family nurse practitioner licensed in the state of Michigan or physician assistant licensed in the state of Michigan.

Family certification preferred.

2 years of nurse practitioner/physician assistant experience preferred. Home care experience preferred.

Demonstrated understanding of the philosophical and technical aspects of Primary and Palliative Care medicine.

Proven ability to work with an interdisciplinary team from varied backgrounds.

Proven experience having difficult conversations with patients and their families preferred.

Demonstrated knowledge of end-of-life issues and advanced care planning preferred.

Commitment to of the principles of quality improvement.

Proven self-directed professional with the ability to make independent judgments in providing direct patient care.

Computer literacy required.

Meets Home Health and Medicare standards as evidenced by criminal background check and fingerprinting.

Possesses current Michigan motor vehicle license, ability to drive a car, and an insured vehicle capable of transport to patient homes or other offices in various weather conditions.

Meets MHH established requirements for proof of health status. Physically able to lift 35 pounds. Demonstrates ability to move, position and transfer clients utilizing good body mechanics, lifting techniques and/or transfer assistive devices to avoid manipulating more than 35 pounds.

CPR certification required.

ORGANIZATION:

Clinical practice supervised by the Home-Based Primary Care Physician.

Reports to the Project Manager for the Home-Based Primary Care project.

Provides clinical direction as required within a multidisciplinary treatment team.

Participates in effective interdisciplinary care coordination, identification of problems, development of a plan of care, adherence to the plan of care and discharge planning through Interdisciplinary Team reviews and huddles.

Interacts interdependently with the Home Care/Palliative Care/ Hospice interdisciplinary teams, physicians, nurses, ancillary staff, other community personnel, and Munson Medical Center staff.

Prescriptive authority is provided by unit-specific specialty physicians, under the Michigan board of Nursing and DEA regulations.

Participates actively in a continuous quality improvement process to build the Home-Based Primary Care program.

SPECIFIC DUTIES:

Supports the Mission, Vision and Values of Munson Home Health.

Embraces and supports the Performance Improvement philosophy of Munson Healthcare.

Embraces and supports the Triple Aim in Health care and Patient Centered Medical Home philosophies.

Promotes personal and patient safety.

Uses effective customer service/interpersonal skills at all times.

Complies with standard precautions, infection control, and safety procedures.

Assesses patient, conducts physical examination, orders and interprets diagnostic tests and procedures relevant to the patient's current condition, and collects health data in a systematic and ongoing manner while involving the patient, family, and other health care team members as appropriate.

Determines the priority of data collection based on the patient's immediate condition or needs and understanding of the patients' long terms goals.

Provides direct care including prescribing medications and therapies, consultation with/or referral to other health care providers and minor procedures as needed.

Evaluates the patient's progress toward attainment of outcomes and includes the patient, family, and team as appropriate. Documents the patient's responses to the interventions.

Derives diagnoses from the assessment data and involves the patient, family, and team members in formulating individualized outcomes.

Provides clinical decision making that targets unmet clinical needs and supports the patients long term health care goals reflected in the plan of care.

Employs health teaching and health promotion strategies.

Consults with other health care providers for patient care as needed.

Assigns or delegates tasks consistent with organizational policies, procedures, legal, and regulatory requirements, according to the knowledge and skills of the designated caregiver.

Communicates and counsels patients and families in dealing with chronic disease issues that will affect their care and long-term health care goals.

Prepares accurate and complete documentation in the electronic medical record in a timely manner.

Complies with MHH and department policies, procedures and guidelines.

Participates in agency peer record review, peer field observations and in-services as appropriate.

Employees with e-mail are required to maintain proficiency in the basic functions of the program and are also required to regularly check email and keep calendars up to date.

Performs all other duties and responsibilities as assigned.