Nurse Practitioner (45073)

Health@Home is an innovative home-based primary care program developed in partnership with the Neighborhood Health Plan of Rhode Island and members' primary care teams. The program delivers evidence-based care that is both high-quality and cost-effective, aiming to enhance the quality of life for Rhode Island members.

This role provides home-based primary care for Neighborhood Health Plan members with complex medical and social needs. An interdisciplinary team-comprising Nurse Practitioners and Community Health Workers-provides personalized care aimed at improving health outcomes, enhancing community well-being, and reducing healthcare costs. Nurse Practitioners collaborate with case management, pharmacy, and behavioral health to address barriers to care. Program goals include reducing hospitalizations and improving overall member wellness.

The Nurse Practitioner is responsible for managing member care in alignment with established standards of practice, including health assessment, diagnosis, care planning, treatment implementation, and ongoing evaluation. Care is delivered in close collaboration with the member's primary care provider and the broader healthcare team to ensure continuity and quality. The Nurse Practitioner conducts comprehensive, home-based physical assessments for members with complex and chronic conditions, fostering trust and rapport to support long-term engagement. They educate members, families, and caregivers on safe and effective care practices, promoting optimal function and independence. Teaching strategies are tailored to each member's learning needs, readiness, language preferences, and cultural values. While care is primarily provided in the member's home, the NP may offer support in other settings as needed to meet individual care goals.

Duties & Responsibilities:

Responsibilities include, but are not limited to the following:

• Perform 4-6 home visits per day to assess each member's needs and develop or update a comprehensive, individualized care plan. This process is conducted in collaboration with the member, care team, Primary Care Provider (PCP), specialists, and other service providers. Deliver evidence-based care that addresses challenges in navigating the healthcare system and enhances the member's quality of life.
• Optimize management of chronic medical conditions, assess the home environment and social determinants of health, provide education to patients and caregivers, and develop proactive, individualized care plans.
• Make home visits to monitor and track each member's clinical status and delivers care in the home
• Conduct acute care and wellness visits for at-risk members, with a focus on reducing potentially preventable emergency department visits and hospitalizations.
• Communicate and collaborate with primary care provider offices to offer home-visits for their most at risk, complex, vulnerable patients
• Conduct ongoing assessments of identified problems, treatment response, adherence to therapeutic regimens and medications, and progress toward established goals.
• Understand the importance of quality metrics and interpret to improve health outcomes
• Effectively delegate responsibilities to the Community Health Worker & Community Health Coordinators and fosters collaborative teamwork to ensure comprehensive, patient-centered care.
• Orders and interprets diagnostic and therapeutic tests relative to member's needs
• Prescribe and adjust medications and treatments based on a sound understanding and interpretation of clinical indicators and findings
• Help members and caregivers understand their health condition(s) and develop strategies to improve their health and well-being
• Observe safety and security procedures; reports on potentially unsafe conditions
• Determine the need for consultation from specialists and make referrals as necessary
• Collaborate with multidisciplinary team members by making appropriate referrals to Care Management team, behavioral health and other services
• Collaboratively support both medical and behavioral chronic and acute conditions, working closely with specialty providers and interdisciplinary team members to ensure coordinated, high-quality care.
• Collaborate with PCPs, Emergency Department (ED)s, Hospitalists, Discharge Planners and other allied care providers
• Coordinate and authorize all skilled and ancillary services, including Durable Medical Equipment (DME) and supplies
• Facilitate and participate in member care conferences and educational meetings, supporting informed decision-making by providing educational tools to staff, members, and families.
• Establish and maintain an ongoing working relationship with providers and other appropriate community resources/agencies
• Document member encounters, updates medical records and the EMR within established timeframes, and records care plans, communications, rationale for plan changes, and collaborative discussions.
• Collaborate with Neighborhood staff in support of organizational objectives
• Other duties as assigned