Nurse Practitioner Acute Gerontology

Job Summary:

Coordinates case management for members who present in the hospital for ER visits. Screens patient for appropriateness of inpatient admission and/or complexity and assist with transfer to MOA for higher level of care, as necessary. Provides and ensures high quality care to include assessment, evaluation, development, facilitation, and implementation of individualized plans of care. Provides consultation and education to other health care providers. Collaborates with special work teams in developing programs to support continuity of care. Provides consultative and clinic nurse specialist/nurse practitioner services for homecare patients. Collaborates with physicians in providing direct primary, secondary and tertiary care services in outpatient, home, and community settings with emphasis on managing ER visits and home care. Provides post hospital/ER discharge follow up visits e.g., phone/video appointment to prevent readmission or repeat ED visit.

Essential Responsibilities:

• Screen members who present to the KP contracted ER facility using InterQual tool for medically necessary inpatient admission.
• Works collaboratively with ER provider to determine appropriateness of patient admission; consult with KP providers as necessary.
• Provides consultation and care coordination to members who present to ER. Provides primary care and case management of members in the KP contracted inpatient facility which include intake assessment, evaluation of ER visits, appropriateness for transfer to higher level of care in collaboration with non-KP physician.
• Works collaboratively with hospitals, clinics and community sites in program development, and development of policies, procedures, quality assessment and improvement indicators for these programs. Identifies needs and coordinates in-service programs.
• Encourages and documents advanced directives clarifications. Monitor documents provided to patients including observations, treatments, medications, and instructions according to Regional and/or facility standards. Documents all communications and medical orders.
• Acts as liaison with and oversees facility/family concerns related to ER visits and inpatient admissions or transfers. Participates in patient care conferences with other health care team members to coordinate, discuss, evaluate services provided to patients.
• Provides post hospital discharge and/or post ED follow up e.g., phone or video appointment to do medication reconciliation and address other issues to prevent readmission or repeat visit to the ED.
• May perform patient care to the extent necessary to maintain clinical expertise, competency, and licensing necessary to fulfill job responsibilities and to direct the provision of care on the unit.
• Provides direct patient care on an as needed basis. Provides services that are within scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed.
• Incorporates the KP Nursing Vision, Model and Values throughout their Nursing Practice.