The Community Advanced Practice Clinician ensures that a defined panel of dually eligible individuals receives the highest quality, primary care within the context of a member centric individualized plan of care.The Community APC has the opportunity to use evidence, clinical skills, education, and training to influence the clinical outcomes of CCA’s members by impacting acute care utilization, ensuring optimal treatment for chronic disease management, closing of quality gaps, participation in Annual/Geriatric Assessments, goals of care conversations, advance care planning, and delivering palliative and end of life care.
The Community APC will maintain close contact and collaboration with the member’s network PCP, providers, and specialists in the development and implementation of clinical plans of care.
As an integral part of an Interprofessional Care Team and based on the fluctuating needs of the defined panel of members, the Community Advanced Practice Clinician will engage in regular assessments, visits at regularly scheduled intervals, and conduct acute visits to ensure that members’ Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs.Engagement by the APC can occur in two different ways.
Episodic care is triggered by an acute event or significant change in condition of a member which necessitates close, short term follow up by an Advanced Practice Clinician. Longitudinal enhanced primary care is delivered to members who are medically complex, with limitations that create a barrier for traditional in office visits.
The role also includes performing a discrete set of care management/care coordination functions, including the adjustment of the member centric care plan and authorization of appropriate durable medical equipment and services.
- Performs both urgent and routine visits on members to evaluate condition and add to the plan of care
- Orders appropriate medical testing to aid in the diagnosis and medical management of acute and chronic diseases
- Leverages CCA clinical resources (InstED) to avoid emergency room visits and inpatient admissions.
- Evaluate test results, appropriately treat member illness and communication/collaborate plan with PCP
- Facilitates and/or delivers preventative care to members according the guidelines deemed appropriate by CCA
- Engages in appropriate clinical collaboration with clinical experts, including the member’s PCP, CCA Medical Directors, and other CCA Advanced Practice Clinicians. Clinical Leadership. Guidelines may vary based on the individual make-up of the member and is based on age, comorbidities, etc.
- If appropriate, provide medical and psychiatric bridge prescribing abilities for members in transition between providers
- Evaluate member’s HEDIS measure needs, write orders as appropriate to manage these gaps and follow up with PCP on results
- Assist with Advanced Care Planning, including establishing goals of care with members and obtaining MOLST forms
- Provides limited regularly scheduled follow up visits for the management of chronic disease . Visits are inclusive of a history of present illness, review of systems, physical exam, ordering of appropriate studies and tests, identification of a definitive diagnosis, adjustment or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation.
- In order to decrease risk of readmission, performs post discharge visits on member members within 48-hours of discharge from either an acute care facility or a skilled nursing facility; performs detailed medication reconciliation, adjust medications as indicated, and ensure appropriate LTSS are in place,
- Liaises with CCA Care Partner and community based PCPs/ Specialists, as needed
- Provides Intermittent Skilled Care as necessary (e.g., wound care,)
- Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly
- Master’s Degree in Nursing or Physician Assistant Studies
- 5+ years’ experience as Registered Nurse or EMT-P in a high touch clinical environment or home care; OR
- 3+ years’ experience as an NP in primary care or care management; AND 2+ years caring for patients/ members with complex medical, behavioral health, and social needs
- 1+ years as CCA Care Partner (or prior similar role) strongly preferred
- Board Certified NP or Physician Assistant with licensure in good standing in the Commonwealth of Massachusetts.
- Current Mass Controlled Substances License required
- Current DEA Controlled Substances License required
- Current CPR or Basic Life Support (BLS) Certification Required
keywords: RN, registered nurse, NP, nurse practitioner, PA, physician assistant, clinical, bachelor's, master's, MSN, integrated care, medical, behavioral, complex care, care management, care delivery, case management, community, home health, hospice, Medicare, Medicaid, MassHealth, Springfield, Chicopee, Athol, Belchertown, Greenfield, Holyoke, Hatfield, Northhampton, Easthampton, Deerfield, MA, Massachusetts
The Community Advanced Practice Clinician ensures that a defined panel of dually eligible individuals receives the highest quality, primary care within the context of a member centric individualized plan of care.The Community APC has the opportunity to use evidence, clinical skills, education, and training to influence the clinical outcomes of CCA’s members by impacting acute care utilization, ensuring optimal treatment for chronic disease management, closing of quality gaps, participation in Annual/Geriatric Assessments, goals of care conversations, advance care planning, and delivering palliative and end of life care.
The Community APC will maintain close contact and collaboration with the member’s network PCP, providers, and specialists in the development and implementation of clinical plans of care.
As an integral part of an Interprofessional Care Team and based on the fluctuating needs of the defined panel of members, the Community Advanced Practice Clinician will engage in regular assessments, visits at regularly scheduled intervals, and conduct acute visits to ensure that members’ Plan of Care is comprehensive and addresses significant medical, behavioral, and social needs.Engagement by the APC can occur in two different ways.
Episodic care is triggered by an acute event or significant change in condition of a member which necessitates close, short term follow up by an Advanced Practice Clinician. Longitudinal enhanced primary care is delivered to members who are medically complex, with limitations that create a barrier for traditional in office visits.
The role also includes performing a discrete set of care management/care coordination functions, including the adjustment of the member centric care plan and authorization of appropriate durable medical equipment and services.
- Performs both urgent and routine visits on members to evaluate condition and add to the plan of care
- Orders appropriate medical testing to aid in the diagnosis and medical management of acute and chronic diseases
- Leverages CCA clinical resources (InstED) to avoid emergency room visits and inpatient admissions.
- Evaluate test results, appropriately treat member illness and communication/collaborate plan with PCP
- Facilitates and/or delivers preventative care to members according the guidelines deemed appropriate by CCA
- Engages in appropriate clinical collaboration with clinical experts, including the member’s PCP, CCA Medical Directors, and other CCA Advanced Practice Clinicians. Clinical Leadership. Guidelines may vary based on the individual make-up of the member and is based on age, comorbidities, etc.
- If appropriate, provide medical and psychiatric bridge prescribing abilities for members in transition between providers
- Evaluate member’s HEDIS measure needs, write orders as appropriate to manage these gaps and follow up with PCP on results
- Assist with Advanced Care Planning, including establishing goals of care with members and obtaining MOLST forms
- Provides limited regularly scheduled follow up visits for the management of chronic disease . Visits are inclusive of a history of present illness, review of systems, physical exam, ordering of appropriate studies and tests, identification of a definitive diagnosis, adjustment or maintenance of an established treatment plan, and consistent follow up of the plan as evidenced in the documentation.
- In order to decrease risk of readmission, performs post discharge visits on member members within 48-hours of discharge from either an acute care facility or a skilled nursing facility; performs detailed medication reconciliation, adjust medications as indicated, and ensure appropriate LTSS are in place,
- Liaises with CCA Care Partner and community based PCPs/ Specialists, as needed
- Provides Intermittent Skilled Care as necessary (e.g., wound care,)
- Documents all activities and results using an Electronic Medical Record, in an effective manner while strictly
- Master’s Degree in Nursing or Physician Assistant Studies
- 5+ years’ experience as Registered Nurse or EMT-P in a high touch clinical environment or home care; OR
- 3+ years’ experience as an NP in primary care or care management; AND 2+ years caring for patients/ members with complex medical, behavioral health, and social needs
- 1+ years as CCA Care Partner (or prior similar role) strongly preferred
- Board Certified NP or Physician Assistant with licensure in good standing in the Commonwealth of Massachusetts.
- Current Mass Controlled Substances License required
- Current DEA Controlled Substances License required
- Current CPR or Basic Life Support (BLS) Certification Required
keywords: RN, registered nurse, NP, nurse practitioner, PA, physician assistant, clinical, bachelor's, master's, MSN, integrated care, medical, behavioral, complex care, care management, care delivery, case management, community, home health, hospice, Medicare, Medicaid, MassHealth, Springfield, Chicopee, Athol, Belchertown, Greenfield, Holyoke, Hatfield, Northhampton, Easthampton, Deerfield, MA, Massachusetts
