What You'll Do:Provide comprehensive primary and geriatric care to medically complex older adults while working collaboratively with the Interdisciplinary Team (IDT) to support participants' medical, emotional, psychosocial, and social well-being. The Nurse Practitioner is responsible for managing acute and chronic medical conditions, coordinating care across multiple healthcare settings, and promoting participant independence and quality of life. This role supports the PACE mission of helping elderly participants remain safely in their homes and communities as an alternative to nursing home placement.
The ideal candidate will have experience working with the elderly population in long-term care, skilled nursing, home health, geriatric care, or similar healthcare settings.
As a member of the PACE Interdisciplinary Team (IDT), the Nurse Practitioner is responsible for:
- Preparing, implementing, and updating comprehensive participant Care Plans in collaboration with the IDT, addressing medical, emotional, psychosocial, and functional needs.
- Providing primary and preventive healthcare services to elderly participants with acute and chronic medical conditions.
- Performing comprehensive history and physical assessments for new participants.
- Conducting reassessments of participants' medical conditions at least every six (6) months and as needed.
- Managing participant care with the goal of supporting aging in place and preventing unnecessary hospitalizations or nursing home placement.
- Reviewing and coordinating outside clinical information, including specialty appointments, hospitalizations, rehabilitation stays, emergency room visits, and skilled nursing facility admissions.
- Working closely with caregivers and families to support participant well-being and continuity of care.
- Providing care in the PACE clinic, participant homes, hospitals, nursing facilities, and other care settings as needed.
- Performing in-home assessments and visits when transportation to the clinic is not reasonable or when clinically necessary.
- Conducting monthly visits for participants residing in long-term nursing facilities or skilled nursing facilities on an ongoing basis.
- Remaining on site at the PACE center while participants are present unless otherwise approved by the Medical Director or Executive Leadership.
- Expected to see a minimum average of five (5) participants per day, including scheduled visits, acute visits, follow-up appointments, and assessments.
- Collaborating with the Medical Director and IDT to ensure timely participant evaluations, treatment plans, and continuity of care.
- Providing clinical oversight and timely medical intervention to reduce avoidable hospitalizations and support participants remaining safely in the community whenever possible.
- Monitoring participant conditions and documenting findings, changes, and interventions in the electronic medical record in a timely manner.
- Communicating effectively with physicians, nurses, social workers, therapists, caregivers, and other members of the IDT.
- Returning calls from participants, caregivers, pharmacies, and staff in a timely and professional manner.
- Participating in on-call rotation coverage for evenings, weekends, and holidays as assigned.
- Assisting with transitions of care and discharge planning.
- Supporting quality improvement initiatives and compliance with CMS, LDH, and PACE regulations.
- Promoting participant dignity, independence, safety, and quality of life.
Competencies- Strong clinical assessment and critical thinking skills.
- Knowledge of geriatric syndromes, chronic disease management, dementia care, and complex medical conditions affecting the elderly population.
- Experience working with elderly participants in long-term care, skilled nursing, home care, hospice, rehabilitation, or PACE settings.
- Ability to foster caring and compassionate relationships with participants and caregivers.
- Excellent interpersonal and communication skills.
- Ability to work collaboratively within an interdisciplinary team environment.
- Strong organizational and documentation skills.
- Commitment to participant-centered care and aging in place.
- Ability to manage sensitive and complex ethical situations with professionalism and compassion.
- Ability to adapt treatment plans to meet the individualized needs of participants.
- Ability to work independently while maintaining strong collaboration with the Medical Director and IDT.
Physical Requirements- Prolonged periods of sitting, standing, walking, and working on a computer.
- Must be able to travel between participant homes, hospitals, nursing facilities, and PACE centers.
- Ability to lift and carry up to 30 pounds.
- Correctable vision and hearing required.
- Ability to communicate effectively in person and by phone.
Physical Demands- Stand less than 33% of time on duty.
- Walk less than 33% of time on duty.
- Sit between 33% and 66% of time on duty.
- Use hands to finger, handle, or feel over 66% of time on duty.
- Reach with hands or arms less than 33% of time on duty.
- Full ability to talk and hear.
Perks!- Medical, Dental, Vision
- FSA, HSA
- Indemnity Plans
- 401k Matching
- Company Paid Life Insurance
- Company Paid STD & LTD
- Wellness Program Incentives
- Employee Referral Bonus
- EAP
- Teladoc and sooo much more!
What You'll Bring:Minimum Educational and General Qualifications- Nursing Degree from an accredited college or university.
- Graduate of an accredited Nurse Practitioner Program.
- Current and unrestricted Louisiana Advanced Practice Registered Nurse (APRN) license.
- Current Louisiana Controlled Dangerous Substance (CDS) license.
- Current DEA registration with prescriptive authority.
- Current BLS certification.
Preferred Qualifications- Five (5) or more years of nursing experience.
- Three (3) or more years of Nurse Practitioner experience.
- Experience working with the elderly population in:
- Long-term care
- Skilled nursing facilities
- Geriatric care
- Home health
- PACE programs
- Assisted living
- Chronic disease management
- Experience managing medically complex geriatric participants in PACE, long-term care, skilled nursing, or home-based care settings.
- Experience working collaboratively with physicians, Medical Directors, and Interdisciplinary Teams (IDT).
- Experience providing care as an alternative to nursing home placement and supporting participants in remaining safely in their homes and communities.
- Strong understanding of the PACE model and the goal of preventing unnecessary nursing home placement and hospitalizations.
- Bilingual abilities are a plus.
