Job Facility: University of Maryland Medical Center
Employment Type: Not Indicated
What You Will Do:
The nurse practitioner (NP) will provide discharge oversight, ambulatory clinical care, and direct the care coordination to hospitalized internal medicine patients. The NP will be responsible for implementation of Re-Engineered Discharge (RED) elements for elderly patients and serve as discharged patients’ interim “transitional” primary care provider.
Responsibilities will include:
In collaboration with the inpatient physicians, bedside nurses, the inpatient care coordination/case management team, and the ambulatory transitional care teams, the NP will assist in identifying appropriate patients for implementation of the Project RED discharge planning pilot.
In collaboration with ambulatory transitional programs, the NP will follow a “panel” of at-risk elderly adult patients during their transition from inpatient to the care of their community primary care providers.
The NP will provide bedside assessment and interventions using the Project RED checklist to assure patient readiness for discharge. This may include medication reconciliation before discharge, augmenting nursing education, and reinforcement of the discharge plan using the “teach-back” method, and arrangements for follow up appointments and home health care needs.
The NP will conduct post-discharge follow-up for select patients including telephone follow-up, and will serve as a point of contact for patients post-discharge. Should the patient need acute ambulatory follow-up, the NPwill arrange to see, treat and follow the patient in the Coordinated Care Center (C3) and will ultimately transition the patient to another care program or to his or her primary care provider.
The NP will utilize C3 resources to provide patient follow-up visits and/or clinical support as needed. The NP may perform medical examinations and evaluations, diagnoses, treatment, follow-up, consultations and health education as needed.
The NP will communicate directly with patients’ primary care providers during their transition to ambulatory/primary care, including transmission of discharge summaries.
The NP may be available to support home-visits with UMMC community health workers or the Mobile Integrated Health providers as appropriate based on patient needs and utilizing telehealth or other opportunities to provide at home support.
The NP will support the other West Baltimore ambulatory programs as a provider and will collaborate inpatients ambulatory care coordination.
What You Need to Be Successful:
Master of Science or Doctorate of Nursing Practice degree with completion of an accredited Nurse Practitioner Program required.
Current state licensure as an Adult-Gero or Family Nurse Practitioner required.
Current BLS certification or obtained prior to providing direct patient care is required.
DEA and CDS eligible.
Care management experience or CCM and at least 3 years of internal medicine experience preferred.
Knowledge, Skills, and Abilities
Knowledge of transitions of care for patients with complex chronic diseases.
Skill in assessing, planning and managing patient care acquired through minimum of
3-5 years clinical NP experience.
Skill in working with internal medicine patients including geriatric patients.
Ability to communicate effectively with various audiences including patients, health care providers, and executive leaders within UMMC.
Ability to work independently and with minimal supervision.