Nurse Practitioner - Residential Care Services

Job Summary

Reporting to the Chief Medical Officer, the Nurse Practitioner provides comprehensive clinical care and care coordination to PACE-RI participants residing in residential care settings, including assisted living facilities and nursing homes. The Nurse Practitioner assesses participant needs, provides direct patient care, develops and evaluates plans of care in collaboration with the interdisciplinary team, and supports continuity of care across PACE, residential care, hospital, specialty, and other healthcare settings.

A primary focus of this role is coordination and follow-through of participant care, including transitions of care, medication list reconciliation, tracking external medical appointments and recommendations, and monitoring individualized care plans and services. The Nurse Practitioner works closely with the PACE interdisciplinary team, residential care staff, participants and families, and external healthcare providers to identify changes in condition, address emerging needs, and coordinate appropriate care.

The Nurse Practitioner functions with clinical independence within the scope of practice and in collaboration with the PACE medical team. Strong communication and relationship-building skills are essential, with the ability to collaborate effectively with PACE physicians, facility medical directors, Directors of Nursing and other residential.

The position may be based from the PACE East Providence location or an associated residential care facility in Cranston and requires regular travel to contracted residential care facilities throughout Rhode Island.

Duties/Responsibilities:

• Provides comprehensive assessment and ongoing management of PACE participants residing in residential care facilities, including assisted living facilities and nursing homes.
• Obtains health histories and performs physical, functional, and mental status assessments; identifies changes in condition and initiates appropriate intervention, consultation, or referral.
• Orders, interprets, and evaluates laboratory, diagnostic, and screening tests and incorporates findings into the plan of care.
• Provides preventive, episodic, and chronic disease care and manages acute and chronic health conditions within the Nurse Practitioner's scope of practice.
• Prescribes and adjusts medications as clinically appropriate and maintains accurate medication lists through medication reconciliation.
• Uses clinical judgment to determine when conditions can be managed within scope of practice and when consultation, referral, or a higher level of care is needed.
• Coordinates transitions of care, including hospital and emergency department discharges, specialty care, and follow-up.
• Tracks external appointments, consultations, testing, and recommendations and communicates relevant information to the interdisciplinary team.
• Monitors participant care in residential care facilities and collaborates with facility staff to address changes in condition and care needs.
• Collaborates with facility leadership, physicians, medical directors, specialists, participants, families, and other healthcare providers to coordinate care.
• Participates as an active member of the PACE interdisciplinary team in care planning and ongoing monitoring and evaluation of participant health status.
• Provides participants and families with education, counseling, and guidance regarding health maintenance and treatment plans.
• Maintains accurate and timely documentation of assessments, orders, clinical findings, care coordination, and services in the electronic health record, completing documentation within required timeframes.
• Participates in participant-related conferences, care planning meetings, and other clinical meetings as designated.
• Participates in scheduled on-call responsibilities as assigned.
• Travels to PACE sites, residential care facilities, and other community settings to provide participant care as needed.
• Maintains proficiency with electronic health records and other systems necessary to perform job responsibilities.
• Protects the privacy and confidentiality of participant health information and protected health information (PHI) in accordance with HIPAA, applicable laws and regulations, and organizational policies.
• Participates in organizational committees, initiatives, and other activities as assigned.
• Performs other related duties as required and assigned.