CIC Advanced Practice Clinician

Position Summary:
Commonwealth Care Alliance's (CCA) Community Intensive Care (CIC) programing is responsible for providing care delivery and care management to a specific panel of high risk and complex people. This panel of patients incorporates the care of individuals with significant medical, behavioral, and social complexities that require intensive care management and care delivery.

Within the CIC Program, the Advanced Practice Clinician (APC - NP or PA) serves as a lead for medical care delivery and care coordination for the most complex medical and behavioral health patients. The APC functions within and is integral in a highly skilled interprofessional team model. The APC ensures that a defined panel of patients receive the highest quality, community-based skilled care within the context of a patient centric individualized plan of care. The APC uses evidence-based care approaches, clinical skills, education, and training to influence the clinical outcomes of assigned patients by impacting acute care utilization, ensuring optimal treatment for chronic disease management, closing of quality gaps, goals of care conversations and advance care planning.

Additionally, the APC interfaces closely with the patient's external care team members including PCPs, care providers, specialists, vendor services, among others to maintain collaboration with the patient's entire healthcare team. The APC utilizes all technological modalities and conducts visits within the patient's home, community, and area facilities to ensure connection and to optimize care. The APC will interface with patients during transitional space to promote hospital avoidance and readmission reduction. Additionally, the APC will provide ongoing chronic disease management, urgent visits, promote preventative care and wellness, and provide end of life/palliative care. The APC engages in visits at regularly scheduled intervals to conduct regular assessments to ensure that their patient's Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs. The APC will delegate appropriate visit follow-ups to their interprofessional care team.

This position requires in-person visits to patients in their homes and the community across various locations.

This position reports to the CIC APC Clinical Manager.

Supervision Exercised:
* No, this position does not have direct reports.
Essential Duties & Responsibilities:
The primary function of the CIC APC role is delivering care to CCA's most complex patients, providing care management and care coordination support, and collaborating with external providers with the goal of delivering comprehensive care.

Essential Duties include - best in class patient care; clear, concise, and effective communication and documentation; and interdisciplinary collaboration with a variety of stakeholders internally and externally.

Patient Care:
The APC is expected to perform longitudinal routine, and urgent care for an attributed patient panel including (but not limited to):
* Interface with inpatient or post-acute care team and patient to optimize discharge planning in collaboration with Transitions of Care - (done in-person at facility, telephonically, or virtually)
* Timely Medical post hospital discharge with focus on hospitalization and utilization reduction
* Goals of Care conversations, including completion of Health Care Proxy and MOLST forms
* Long Term Services and Supports (LTSS) assessments and referrals to LTSS providers
* Medication Reconciliation
* Proactive and routine well-visits and preventative care
* Evaluate HEDIS Measure Gaps and work towards closure of gaps in clinical practice and in collaboration with patient's external providers.
* Evaluate Hierarchical Condition Categories (HCC) and work to recapture
* Urgent, episodic, or un-well visits
* Point of care testing and venipuncture
* Vaccination administration
* Routine medical follow ups and monitoring - ability to delegate follow ups to appropriate support staff
* Conduct multiple patient visits within each business day balancing routine, scheduled encounters with episodic or urgent visits to maintain expected productivity
* Prescribe or bridge prescribe medications based on medical evaluation for acute and chronic conditions independently and in collaboration with PCP and/or external providers.
* Evaluate for and prescribe necessary Durable Medical Equipment (DME)
* Monitor response to action or treatment plan with appropriate evaluation and adjustments.
* Initiate necessary action or treatment changes adhering to CCA Policies and Procedures and within scope of licensure.
* Leverage emergency medical or psychiatric services as indicated to mitigate Emergency Services and inpatient admissions

Documentation/Accountability:
* Document all visits with focus on clear, comprehensive, and concise charting. Must be able to document in English.
* Identify, document, and execute a patient-centric plan of care. Ability to communicate and delegate care plans as appropriate utilizing multiple modalities of communication.
* Completion of all tasks within appropriate timelines as outlined in Scopes of Practice and CCA Guidelines.
* Comply with organizational policies and procedures.
* Identify and initialize a plan to resolve areas of opportunity to meet Key Performance Indicators (KPIs).
* Maintain patient and employee confidentiality.
* Participate in evaluation of own performance and progress

Interdisciplinary Team Collaboration:
* Serve as a clinical mentor and leader for medical care
* Proactively and collaboratively work with patients' Primary Care Provider (PCP) and other external providers to ensure a cohesive medical treatment plan is delivered.
* Conduct on-going and effective collaboration and communication with external providers, including but not limited to Primary Care staff, specialty services, LTSS coordinators, Aging Service Access Points (ASAPs), visiting nurse services, care attendants, patient designated contacts, and next of kin.
* Conduct on-going and effective collaboration and communication with interdisciplinary team including but not limited to, Health Plan Care Team members, Community Licensed Practical Nurses, Community Health Workers, Community Behavioral Health Clinicians, Medical Directors, Palliative Care Team, Psychiatric services team, Rehab Team, Crisis Response workers, patient Services representatives, administrative staff, and CCA Leaders.
* Identify and lead ad hoc case reviews with internal/external care team as needed.
* Participate in committees and workgroups that promote clinical excellence and help to advance CCA's mission and business objectives
* Participates in CCA quality improvement efforts
* Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects

Other duties as assigned.

Working Conditions:
* This position requires in-person visits to patients in their homes and will support patients across various locations.
* This position requires travel to CCA sites and offices per required need for various team meetings.
* Valid driver's license with no restrictions. Ability to be active and mobile across assigned catchment area.
* COVID-19 vaccination is required
* Compliance with all Community Clinician Occupational Health Requirements

Other:

Physical requirements:
* The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job
* Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
* While performing the duties of this job, the employee is regularly required to stand; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear
* The employee is occasionally required to walk; sit; and stoop, kneel, crouch, or crawl
* The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move more than 100 pounds
* Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus
* Must be able to come to the local CCA office
* May require meetings across the state

Required Education (must have):
* Master's Degree in Nursing or a degree in Physician Assistant Studies

Desired Education (nice to have):
* Doctor of Nursing Practice

Required Licensing (must have):
* Board Certified Nurse Practitioner or Physician Assistant with licensure in good standing in the state served
* If works in MA role requires MassHealth Enrollment:
* Current Controlled Substances License
* Current DEA Controlled Substances License
* Current CPR or Basic Life Support (BLS) Certification

Required Experience (must have):
Must meet one of the following requirements:

* 2+ years' experience as NP or PA caring for patients with complex medical, behavioral health, and social needs; preferred experience in community setting; OR
* 1-year experience as NP or PA in primary care or care management AND 3+ years' experience as Registered Nurse or EMT-P in a high touch clinical environment or home care; OR
* If new NP or PA graduate, must have 5+ years' experience as Registered Nurse or EMT-P in a high touch clinical environment or home care.

Desired Experience (nice to have):
* Experience with electronic medical record strongly preferred (eCW a plus)
* Experience working with managed care population
* Experience with Medicaid or Medicare programming and insurance products (i.e. ACO, MCO, PACE, or SCO)

Required Knowledge, Skills & Abilities (must have):
* Proven skills, knowledge base, and judgement necessary for independent clinical decision making in alignment with clinical licensure, ability to problem solve.
* Sufficient visual/hearing ability, with or without reasonable accommodation, to comprehend written/verbal communication and perform physical exams and assessments of patients
* Strong and effective communication skills, written, verbal, and via electronic modalities
* Effective teaching skills
* Mediation and conflict resolution skills
* Effective organizational and time management skills
* Ability to advocate for a complex patient population in a culturally competent manner

Required Language (must have):
* English

Desired Knowledge, Skills, Abilities & Language (nice to have):
* Willing to learn and utilize telehealth technologies (video, chat, etc.), when appropriate, for a variety of clinical care and care management services.
* Demonstrated ability to utilize and toggle through multiple EHR platforms
* Bilingual or multi-lingual