Job Summary
Job Description
Job Description:
The Advance Practice Clinician (APC) is responsible for providing direct patient care in short term rehab and skilled nursing settings. The APC participates as a leader of the Post-Acute Care Team (PACT) for designated Skilled Nursing Facilities (SNFs). Provides appropriate evidence-based medicine. The purpose of the team is to improve patient outcomes and reduce the overall cost of care. Coordinates care with discharging hospitalists, primary and specialty care physicians, hospital and clinic based care managers and SNF provider and social work staff. Work with SNF staff in developing patient-specific post-SNF care plan, reconciling medications at discharge, and communicating with clinic based care manger to assure smooth post-SNF transition. Works closely with the PACT medical director who provides physician oversight for the PACT program. Demonstrate flexibility, problem-solving skills, ability to work independently and as part of a team.Scope
The APC plays a crucial role in managing the medical needs of skilled nursing patients in 3 - 5 skilled nursing facilities that are geographically proximate. The APC is expected to establish and build strong working relationships with the administrator, Director of Nursing and facility therapy and clinical staff throughout their designated SNFs. The APC will act as the primary point of contact for medical issues and questions for Intermountain patients during their short-stays at the SNFs. Practice within scope of licensure (defined for PAs and APRNs, respectively, in the Utah Physician Assistant Act/Rules (58-70a, R156-70a)
and Utah Nurse Practice Act/Rules (58-31b, R156-31b)), national certification, education, training, and consistent with Intermountain Healthcare approved privileges and/or other aspects of the credentialing process.
Job Essentials
Will see patients at their place of care including providing direct patient care in short term rehab and skilled nursing settings
Appropriately and accurately documents patient visits using patient charting software
Appropriately and accurately provides necessary documentation of care plan within SNFs medical record keeping systems
Available via phone for SNF staff during their regular business hours
Available to respond to family/patient via phone during designated hours
Participates in on-call schedule that may include nights, weekends, admissions and in-person visits
Reviews, approves and modifies admission and discharge orders
Provides in-person assessment visit to all patients after admission
Initiates/documents palliative care discussion with patient and family
Determines if Health Care Proxy is correct and invoke if appropriate
Consults supervising physician and/or facility medical director as needed
Complies with all regulations and maintains security of protected health information (PHI)
On average, expected to meet patient load productivity, and complete charting for visits within a predetermined timeframe
Identifies gaps in clinical skills/competency of SNF nursing staff, if any, and collaborates with SNF leadership to develop plan to address
Routine Visits
Initiates and reviews orders, including medications, during each visit
Orders necessary diagnostic tests, procedures and therapeutic interventions
Reviews labs, radiology reports, and other testing
Talks to and examines each assigned skilled patient on daily rounds to assess patient?s medical stability
Assesses acute mental status changes via non-pharmacologic or pharmacologic measures
Consults/coordinates with specialists. Reviews notes of consultative providers/specialists
Communicates/assess rehab progress on a regular basis
Discusses concerns with patient, family, facility nursing and rehab staff, and case management/SW routinely regarding acute and chronic illness management
Attends family meetings
Informs patients' primary care physician and/or PACT medical director of significant changes in medical condition
Participates in facility's utilization meetings including re-admission reviews
In conjunction with facility providers, assess patients with acute or worsening medical conditions to determine if treatment could be provided in SNF, or if ED or direct hospital admission is appropriate
Discharge Activities
Develops a patient specific discharge plan utilizing input from facility nursing staff, therapy providers, social services staff and community based care manager. Identify barriers to discharge and plan for addressing concerns
Creates detailed discharge summary for all patients, including medication reconciliation and providers to primary care physician, community care manager and specialist, if appropriate at time of discharge.
Informs patients of the process for discharge and assures discharge plan is implemented