Nurse Practitioner, Transitions of Care, 40 HHours (Days)

Company: Boston Medical Center (BMC)
Location: Boston
Posted on: March 20, 2025

Job Description:

Position SummaryThe Hospital ReAdmission Reduction Program (HARP) is a transitions of care program at BMC aimed at improving care and reducing readmissions for adult patients with medicare or who are part of the Boston ACO. The goal of this program is to provide an additional layer of support to patients who are discharging from the hospital to a skilled nursing facility to their homes. This program will support patients in the 30-60 days after hospital discharge and provide wrap-around care for patients.As a member of the team, the NP will provide care for patients primarily in the community setting through a series of home visits and phone calls. The NP will support transitions of care for patients returning to community and facility settings from BMC. The NP specifically works with patients who have a high risk of readmission. By complementing existing care teams on the inpatient and outpatient side, the Transitions of Care NP serves a critical role in connecting the dots across care providers and community agencies. The team works at inpatient facilities, and aims to fully integrate with inpatient care operations - documenting in local medical records, participating in care planning efforts, etc. to ensure seamless care planning for patients while also serving as the link to continuing outpatient care. This individual will work in partnership with Community Health Workers (CHWs) to complete of assigned tasks related to this care plan. Clinical expertise in common high-risk medical conditions (e.g. CHF, diabetes, COPD, etc.), familiarity with home health and community-based resources, as well as excellent interpersonal skills, patient engagement skills and the ability to work independently and collaboratively are key requirements of the job.Position: Transitions of Care NPDepartment: Value Based CareSchedule: Full TimeKey Functions/ResponsibilitiesESSENTIAL RESPONSIBILITIES / DUTIES:

• Identify and recruit appropriate patients for care management from lists and referrals, in collaboration with supervisors and local clinical site leaders
• Ability to execute core care management duties:
  • Comprehensive assessment: bio-psycho-social-spiritual
  • Collaboration with patient and care team to develop patient-centered care plan, with particular focus on chronic disease management, social determinants, transitions of care and advanced care planning (HCP, MOLST)
  • Implementation of care plan;
  • Collaboration with community partners, such as VNA agencies, caregiver programs (PCA, ADH, AFC), DME providers and social service agencies, and skilled nursing facilities
  • Assessment of goal completion, with transition of patient to inactive or graduated status as appropriate.
  • Uses reflective, empathetic language and open-ended questions to understand what the patient truly wants for him/herself beyond being healthy and staying out of the hospital
  • Meet the patient where he/she is; observe the patient without intervention or judgment
  • Has knowledge of common chronic medical conditions presented in the population served and is able to:
    • Educate the patient on their medication conditions and medications, and build their self-management skills;
    • Use motivational interviewing to promote behavioral change;
    • Assess, triage, and rapidly respond to clinical changes that could lead to the need for emergency services if not intervened upon.
    • Delegates assignments to Community Health Workers and/or Patient Navigators or Social Workers and follows up on completion.
    • Meets regularly with leaders at the local clinical site (Primary Care, ED, inpatient), and care management supervisor, to triage program issues appropriately.
    • Participates in local site operations, including team meetings, curbsides with care team members, etc.
    • Actively participates in planning and growth of program with relevant stakeholders as needed
    • Facilitates interdisciplinary consultation on patient's behalf through participation in rounds, team meetings and clinical reviews
    • Complies with established metrics for performance and adheres to documentation and work flow standards
    • Maintains HIPAA standards and confidentiality of protected health information.
    • Adheres to departmental/organizational policies and procedures.EducationJOB REQUIREMENTS
      • Master's degree in nursing required. Completion of an accredited educational program for nurse practitioners required.Certificates, Licenses, Registrations Required
        • Current license to practice as a registered nurse in the Commonwealth of Massachusetts with authorization by the Board of Registration in Nursing to practice in an expanded role.
        • Registered with the ANCC or other accrediting organization for Nurse Practitioners.
        • Registered with the State of Massachusetts and DEA for prescription writing privileges.
        • Current BLS and ACLS Certifications.Experience
          • Minimum of three years of current clinical nursing experience and two years experience in adult practice required.
          • Prior experience in-related clinical practice preferred.
          • Expert clinical judgment and ability to be self-directive and demonstrate initiative in an expanded role.Knowledge And Skills
            • Demonstrated critical thinking, problem solving and conflict resolution skills.
            • Full command (verbal and written) of the English language.
            • Demonstrated ability to apply principles of adult learning to provide effective patient and/or family education.
            • Organizational skills to set priorities and efficiently complete assigned work.
            • Effective interpersonal skills to facilitate communication with the various members of the health care team, patients and families.
            • Computer proficiency inclusive of the ability to access, enter, and interpret computerized data/information required.
            • Physical ability to meet the core job responsibilities in accordance with the practice setting demands for the patient populations regularly served.Working And Physical Effort
              • Regular and reliable attendance is an essential function of the position.This position requires working from home, community, and hospital.Equal Opportunity Employer/Disabled/Veterans

Keywords: Boston Medical Center (BMC), Boston , Nurse Practitioner, Transitions of Care, 40 HHours (Days), Healthcare , Boston, Massachusetts