Nurse Practitioner - Residential Care Services

Job Summary

Reporting to the Chief Medical Officer, the Nurse Practitioner provides comprehensive clinical care and care coordination to PACE-RI participants residing in residential care settings, including assisted living facilities and nursing homes. The Nurse Practitioner assesses participant needs, provides direct patient care, develops and evaluates plans of care in collaboration with the interdisciplinary team, and supports continuity of care across PACE, residential care, hospital, specialty, and other healthcare settings.

A primary focus of this role is coordination and follow-through of participant care, including transitions of care, medication list reconciliation, tracking external medical appointments and recommendations, and monitoring individualized care plans and services. The Nurse Practitioner works closely with the PACE interdisciplinary team, residential care staff, participants and families, and external healthcare providers to identify changes in condition, address emerging needs, and coordinate appropriate care.

The Nurse Practitioner functions with clinical independence within the scope of practice and in collaboration with the PACE medical team. Strong communication and relationship-building skills are essential, with the ability to collaborate effectively with PACE physicians, facility medical directors, Directors of Nursing and other residential. 

The position may be based from the PACE East Providence location or an associated residential care facility in Cranston and requires regular travel to contracted residential care facilities throughout Rhode Island.

Duties/Responsibilities:

• Provides comprehensive assessment and ongoing management of PACE participants residing in residential care facilities, including assisted living facilities and nursing homes.
• Obtains health histories and performs physical, functional, and mental status assessments; identifies changes in condition and initiates appropriate intervention, consultation, or referral.
• Orders, interprets, and evaluates laboratory, diagnostic, and screening tests and incorporates findings into the plan of care.
• Provides preventive, episodic, and chronic disease care and manages acute and chronic health conditions within the Nurse Practitioner's scope of practice.
• Prescribes and adjusts medications as clinically appropriate and maintains accurate medication lists through medication reconciliation.
• Uses clinical judgment to determine when conditions can be managed within scope of practice and when consultation, referral, or a higher level of care is needed.
• Coordinates transitions of care, including hospital and emergency department discharges, specialty care, and follow-up.
• Tracks external appointments, consultations, testing, and recommendations and communicates relevant information to the interdisciplinary team.
• Monitors participant care in residential care facilities and collaborates with facility staff to address changes in condition and care needs.
• Collaborates with facility leadership, physicians, medical directors, specialists, participants, families, and other healthcare providers to coordinate care.
• Participates as an active member of the PACE interdisciplinary team in care planning and ongoing monitoring and evaluation of participant health status.
• Provides participants and families with education, counseling, and guidance regarding health maintenance and treatment plans.
• Maintains accurate and timely documentation of assessments, orders, clinical findings, care coordination, and services in the electronic health record, completing documentation within required timeframes.
• Participates in participant-related conferences, care planning meetings, and other clinical meetings as designated.
• Participates in scheduled on-call responsibilities as assigned.
• Travels to PACE sites, residential care facilities, and other community settings to provide participant care as needed.
• Maintains proficiency with electronic health records and other systems necessary to perform job responsibilities.
• Protects the privacy and confidentiality of participant health information and protected health information (PHI) in accordance with HIPAA, applicable laws and regulations, and organizational policies.
• Participates in organizational committees, initiatives, and other activities as assigned.
• Performs other related duties as required and assigned.

Required Skills & Abilities:

Ability to maintain confidentiality

Dependable and punctual with ability to maintain consistent attendance 

Ability to read, write and comprehend English 

Ability to maintain sound judgement under stress and communicate effectively 

Ability to proficiently perform clinical/skilled tasks associated within scope of position

Proficiency with MS Office Suite or similar software 

Education Requirements

Master's Degree, Required

Physical Requirements

Physical ability to regularly stoop, bend, kneel, lift, stand, walk, stretch and reach for extended periods of time. 

Must be able to regularly lift objects up to 25 pounds and at times up to 35 pounds.

Must be able to assist a 200-250 lb participant, using proper body mechanics. 

Must have hearing and vision abilities within normal range (corrected) to drive safely and/or to observe and communicate with participants. 

Must be able to navigate various departments of the organization's physical premises as well as related community care settings. 

Must be able to tolerate conditions typically associated within a medical office and/or home care setting including potential exposure to bloodborne pathogens and infectious diseases. 

Must be able to complete assignments in variable weather conditions and ever-changing and sometimes allergenic environments in participant homes, including extreme heat, humidity, dust, smoke, pet contamination, and cleaning supplies. 

Experience

2 Years of direct clinical work, Preferred

1 Year of experience in a Medical or Geriatric Care setting, Preferred

1 year of experience working with a frail or elderly population, Preferred 

License & Certification Requirements

RI Advanced Practice Registered Nurse (APRN) and Controlled Substance Registration (CSR-APRN) 

Position Requirements

Graduate from an APRN graduate or post-graduate program recognized by the US Secretary of Education and/or the Council for Higher Education Accreditation Certified by the Board in the APRN role and population focus appropriate to education preparation. 

CPR Certification

Driver's License & access to reliable transportation: community-based travel required.