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Job Summary:
The Nurse Practitioner (NP) is responsible for providing direct patient care in a Long-Term Care, Skilled Nursing Facility. The NP will participate as a leader of the skilled nursing facility (SNF) care team. The NP will provide appropriate evidence-based geriatric medicine and coordinate care with hospitalists, primary care physicians and care managers in providing quality, efficient, continuous, and cost-effective care for the residents of the skilled nursing facility.
Essential Functions & Responsibilities:
- Obtains, records, and dictates medical histories and physical examinations.
- Makes daily rounds, records progress notes, writes routine orders (comfort and diet, laboratory tests, non-invasive examinations, etc.).
- Performs procedures such as, general wound care, intravenous (IV) therapy, injections, catheter care, physical therapy, and monitoring of vital signs and medical equipment
- Ordering, performing, and interpreting diagnostic tests such as lab work.
- Act as liaison between patients, nurses.
- Requests consults from appropriate physicians.
- Diagnoses and treats acute and chronic conditions such as diabetes, high blood pressure, infections, and injuries.
- Prescribes medications and other treatments.
- Manages patients' overall care.
- Performs other duties as assigned.
SKILLED NURSING FACILITY SPECIFIC
- Maintains privileges in multiple Nursing Homes as directed by ACA.
- Maintains license and malpractice insurance.
- Consults supervising attending and Medical Director as needed.
- Documents patient visits electronically.
- Participates in documentation and other quality improvement programs.
- Available via phone weekdays 8am until 5pm and when on call.
- Participates in on-call schedule.
- Reviews, approves, and modifies admission orders.
- Creates detailed admit note for each admission within 24 hours of patient admission to SNF, including medication reconciliation.
- Initiates/documents Advanced Directives.
- Determines if Health Care Proxy status is correct and invoke, if appropriate.
DAILY VISITS
- Initiates and reviews orders, including medications, on a daily basis,
- Reviews labs, radiology reports, and consults on all patients.
- Examines and interacts with each assigned skilled-level patient Monday through Friday.
- Writes at least one daily progress note for each assigned patient.
- Assesses each patient's medical stability daily. Consults coordinates with specialists as needed.
- Addresses acute mental status changes via non-pharmacological or pharmacological measures consultation or transfer.
- Coordinates/assesses rehab progress on a daily basis.
- Discusses concerns with the patient, family, rehab and case management. Educates patient and family members regarding acute and chronic illness management.
- Informs attending and or ACA medical director of significant changes in medical condition.
- Participates in weekly utilization meetings collaborating with the SNF care team and ACA care managers.
- Coordinates with PCP's, Hospitalists, ACA Medical Directors and Case Managers.
- Addresses/coordinates any legal issues.
DISCHARGE
- Develops a discharge plan utilizing input from case management and rehab. Identifies barriers to discharge.
- Creates detailed discharge summary for each admission on all patients, including medication reconciliation, and sends to the PCP at the time of the SNF discharge.
- Ensures that patients have all appropriate drug and DME prescriptions at discharge.
- Coordinates visits with the PCP post discharge.
- Sends discharge summary to the PCP at discharge.
- Coordinates transition from skilled to long term placement.
Long-Term Care
- Assists case management in the evaluation of selected long-term patients.
- Follows "new" long term patients every 30 days.
- Assists the attending physician with management for complex long-term patients.
Qualifications:
As an EOE/AA employer, the organization will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status.
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