Job DescriptionA bit more about this role: Devoted Medical was founded on the belief that if we treat each patient like we would our loved ones, we can meaningfully improve healthcare experiences and outcomes for some of America's most vulnerable patient populations. The Intensive Home Care (IHC) Program is at the heart of this goal: we are a highly collaborative, multidisciplinary team of physicians, nurse practitioners, case managers, social workers, community health workers, and scheduling team, united by our mission to build a better care delivery system for Devoted's most complex members. Through a mixture of in-home and virtual interventions, we provide whole-person clinical, social and logistical support for patients with complex chronic conditions, frail elders, and patients at high risk of hospital admissions. We succeed through building trust and relationships with our patients. We start by identifying our patients' values and priorities. We center our work around those values and priorities: we will help patients define goals around them, and pave a clinical pathway that aligns with them.
The IHC Nurse Practitioner is the true champion of our patients' medical care, and plays a critical role in building trusting patient relationships and empowering patients to live healthy, dignified, independent lives.
QualificationsResponsibilities will include:- Conduct a hybrid of in-home and telehealth video visits for Devoted Health members within your patient panel and who are assigned to your geography. In infrequent instances when appropriate and compliant with NP licensure, you may also provide telehealth visits to members located in other geographies in order to support other Devoted Medical service lines.
- Perform comprehensive assessment visits (CAV), comprehensive diagnosis/disease review, medication review, and assessment for quality of care (Stars/Hedis) interventions as well as social and home health/DME needs as a tool to identify patients eligible for IHC enrollment.
- Develop and provide plans of care in collaboration with IHC team members to manage complex patient populations.
- Perform appropriate diagnostic tests and interventions.
- Meet patients' needs through a variety of visit types depending on their need, including chronic care, urgent care, post hospital transition of care, and follow up visits, with collaboration and support from the IHC team.
- Work closely with other members of the patient's care team including their PCP, specialists, and other Devoted teams such as pharmacy, or specialty care. You will also collaborate with the patients' support systems such as family members and caregivers in order to coordinate care for the patient and deliver a collaborative care plan.
- In certain geographies, there may be an infrequent weekend on-call component to support our clinical nurses who triage calls from our members during the weekend.
A day at Devoted could include:Home-based chronic care:
- See patients in their homes 3-4 days per week, 5-7 visits per day dependent on patient needs.
- Provide virtual care (video or telephonic), 8-15 visits per day dependent on patient needs.
- Conduct visits in the Devoted-built Orinoco electronic medical record.
- Conduct structured conversations with patients about their goals and values, so we may align care plans accordingly.
- See patients with multiple medical and psychosocial comorbidities, and appropriately focus on patients' stated needs, as well as their primary morbidity drivers.
- Appropriately document the full extent of each patient's medical complexity.
Interdisciplinary team coordination requires collaboration across the IHC team and Devoted Medical Speciality lines and disease management programs:
- Participate in team huddles with your assigned case manager, community health worker, and social worker 2-3 times per week to discuss complex cases.
- Participate in all team rounds once a week to obtain multidisciplinary team input on medically and socially complex patients.
- Collaborate with Devoted Medical specialty lines (CAV, TOC, virtual urgent care, and disease management).
Building a Panel:
- Onboarding patients into the IHC program by building meaningful relationships to create sustainable patient panels in your geography.
- Your attributable geography can cover an area that will require variable drive times but will fit visit and drive time within the work day.
- Knowing which patients you are responsible for and prioritizing your attention to those patients that most need your time, skills, and attention.
- Being able to down-titrate your attention and time away from patients who are stable.
- Nominating patients from your panel to Team Rounds for interdisciplinary conversation.
- On a quarterly basis, leading a structured conversation around patients in your panel in collaboration with the physician leader, Community Health Worker, Social Worker, and Case Manager to set the care trajectory for each patient over the following 3 months.
Attributes to success:- You're a happy warrior - as long as you're in a great environment with smart, caring people all working together toward a common aim, you're comfortable working hard.
- You are a strong clinician and enjoy caring for adults with multiple complex chronic conditions as if they were your own family patient.
- You are deeply empathetic and humanistic, and want to go the last mile for your patients.
- You are comfortable working with members over video and phone, but also in-person in their homes.
- You can keep track of patients even if you don't have scheduled visits with them, and follow up on their active issues.
- You enjoy a fast-paced, high-energy, organization. Agility and collaboration are key as we will change and improve quickly.
- You are comfortable engaging and learning new technologies including electronic health records, operating systems and programs (Google Office, Slack). You thrive on knowing your work can help make these technologies better for you and your patients.
- You learn from every experience and are not afraid to fail - that's how you're wired.
- Finally and most importantly, you have a passion for making healthcare better, solving complex problems, and supporting the delivery of healthcare that we would want for our own family members.
Required skills and experience:- An unrestricted and active APRN licensure to practice in the assigned geography.
- Current certification in your area of APRN specialization.
- Active BLS at time of hire and must maintain while employed at Devoted Medical.
- Three or more years working as an APRN.
- Experience in primary care, house calls, internal medicine, family medicine, geriatrics, and/or palliative care.
- A strong desire to continue practicing clinical nursing and perform in home visits as well as virtual visits - you believe in the mission of bringing care to where the patient lives.
- Prior home based practice is a plus.
- Prior ICU experience is a plus.
- Team player mentality with a can-do attitude.
- Extra interest in bilingual Spanish or Haitian Creole speakers or strong cultural competencies across a range of cultures.
Salary Range: $125,000 - $140,000 annually
Additional InformationAll your information will be kept confidential according to EEO guidelines.
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