Commonwealth Care Alliance Advanced Practice Clinician in Boston, Massachusetts
The Advanced Practice Clinician II (APC) provides ongoing comprehensive home-based primary care and care management services to CCA members in collaboration with the patients PCPs and the rest of the CCA Primary Care Team which may include CCA RNs, LPNs, Medical Assistants, BH and Rehab specialists etc. Acts as consultant and mentor to other CCA team members which may include RN, LPN, MA, GSSC, LTSC, HOWs.
Commonwealth Care Alliance’s (CCA) iCMP Plus ACO inter-professional teams are responsible for providing primary care and care management to a specific panel of high risk, Medicaid ACO eligible, non-CCA patients. This patient group is made up of individuals with significant medical, behavioral, and social complexities that require intensive case management. This cohort of patients belong to outside organizations that are contracted with CCA to provide this complex care.
Primary care to members -Provides patient-centered, comprehensive home-based primary care to complex adult and geriatric patients (assessment, diagnosis, treatment, referrals) to promote continuity of care by coordinating with PCP and other providers as necessary.
Specialty care to members -Provides urgent/sick/episodic care, post-hospital care and palliative care. Coordinates other specialty services such as behavioral health, psychopharmocotherapy and health education in collaboration with PCPs and CCA clinical specialists as needed.
Professionalism- Exhibits professionalism and the translation of CCAs mission into patient-centered activities and plans of care.
Risk adjustment -Performs and documents Annual Comprehensive Assessments on a panel of members ensuring that CCA is properly funded and quality, patient-centered care is provided. Performs ongoing history, exam and medical decision making including pharmacotherapy in collaboration with internal and external providers.
On call - Provides all services listed above on weekends and holidays, including making visits as needed, in an on-call rotation with NP/PA and RN colleagues.
Clinical documentation - Provide expert-level comprehensive documentation in the clinical record to reflect the true complexity of each members biopsychosocial condition.
Continuing education -Participates in ongoing educational activities and formal CME/CEU courses to advance knowledge base and skills competency and to maintain required licensure and certification
Quality Assurance -Ensures that clinical service delivery meets CCA standards as outlined in policies and standing operating procedures. Reviews quality metrics and develops plans to address deficiencies or substandard outcomes accordingly
Teamwork -Works effectively and collaboratively with colleagues to ensure satisfactory patient outcomes and maintains patient panel in collaboration with RN co-care manager.
Leadership - Provides consulting and mentoring to new clinicians and CCA Primary Care Teams. Models professionalism and the translation of CCA's mission into patient-centered activities and plans of care
Autonomy -Works effectively and independently to problem solve. Uses appropriate time management and offers flexibility in team setting. Takes ownership of clinical decisions and offers consultation and guidance to peers. Offers constructive solutions to problems and is able to make clinical suggestions for further patient care.
Skills Building -Has willingness to learn new and develop existing clinical skills, including a broad range of nursing tasks. Provides positive and constructive feedback for workflow processes. Supports Clinical Education Team by mentoring new and existing staff and offering teaching opportunities and in services as able
Clinical Program Development -Assists CCA management and leadership with the development, refinement and enhancement of clinical programs, initiatives, processes, policies, workflows, and projects
3-5 years experience
Graduation from an accredited NP or PA program ANCC or AANP certification for NPs and NCCPA certification for PAs
Bachelor's Degree or equivalent experience
Licensure to practice in the state of MA
Mass Controlled Substance Registration DEA Registration
Current BLS for Healthcare Providers Certification
Relevant work or education-related clinical experience required.
Must be able to drive with an unencumbered license
Must be proficient in the use of stethoscope, sphygmomanometer, pulse oximeter, otoscope, ophthalmoscope.
Must be able to self-identify learning needs for equipment that may not be a part of everyday use: glucometer, Coagu-Check, phlebotomy supplies, catheterization supplies, wound care supplies and equipment, updraft equipment, inhalers and spacers, and other member-specific supplies and equipment, as appropriate. Standard Office equipment
CCA serves a high-risk patient population which is medically/socially and behaviorally complex. Clinicians see members in the community: in homes, group homes, shelters, primary care clinics, assisted living facilities and hospitals. It involves constant travel within CCAs service area.
Proven skills and knowledge necessary for independent clinical decision making at the NP/PA level Must have strong primary care skills. Proficient in taking medical history, performing physical exam and assessment, determining differential diagnosis based on symptoms and exam findings, ordering and interpreting laboratory and diagnostic tests, and utilizing clinical judgment to determine appropriate treatment plan.
Must be comfortable working with patients who have behavioral health diagnoses; psychiatric disorders, substance abuse or addictions Makes independent clinical decisions daily that affects clinical and financial outcomes while utilizing Clinical Decision Support Tools
Collaborates with administrative, clinical and medical leadership on decisions that are not directly related to patient care. Decision making involves diagnosing, treating and prescribing medications and medical therapeutics. Decisions around assessment and testing, ethical dilemmas, complex clinical situations and service needs are made in conjunction with the clinical team and with reference to CCAs Clinical Decision Support Tools. Complexity of this role is advanced
On a daily basis, makes independent and collaborative medical decision on complex patients in a fast-paced and constantly evolving work environment
External Company Name: Commonwealth Care Alliance, Inc.
External Company URL: http://www.commonwealthcarealliance.org/
Actual Work Location: Charlestown, MA