Primary Care Nurse Practitioner

Key Areas

Key Responsibilities and Duties of the Job

Primary & Participant Care

90%

• Promote aging in place by preventing unnecessary hospitalizations, ED visits, and nursing home admissions.
• Provide excellent geriatric care, focusing on participant autonomy and dignity, particularly regarding advanced care planning.
• Maximize participant well-being through proactive health care maintenance, regular visits, and care plan adjustments based on life expectancy and frailty.
• Support caregivers, reduce caregiver burden, and ensure early family involvement in care planning.
• Document all Hierarchical Condition Codes (HCCs) and identify previously missed diagnoses to enhance care outcomes.
• Provide primary care to participants within an MD/NP co-management model, ensuring alignment with best practices, clinical protocols, and relevant guidelines from organizations including the American Geriatrics Society (AGS), PALTMed, National PACE Association (NPA), and the American Association of Hospice and Palliative Medicine (AAHPM).
• Focus on the 4 Ms of an Age-Friendly Health System and make care decisions through the lens of aging and frailty.
• Complete initial, semi-annual, transition of care, 60-day assessments, and acute or unscheduled visits as clinical indicated.
• Visits may occur in the clinic, in the persons home, in contracted facilities, and elsewhere as needed
• Develop and implement patient-centered care plans, focusing on both acute and chronic conditions, in collaboration with the IDT.
• Manage chronic conditions and acute illnesses, with an emphasis on holistic, evidence-based care that aligns with participant goals and preferences.
• Recognize and address behaviors related to dementia and delirium and respond in accordance with the recommendations of the above societies.
• Engage in reoccurring goals of care conversations, especially during acute changes, and incorporate motivational interviewing techniques to facilitate these discussions.
• Provide preventive care (immunizations, screenings, health maintenance) and health education, empowering participants and caregivers.
• Prescribe medications and make referrals to specialists judiciously, ensuring personalized care.
• Manage care in contracted settings (nursing homes, hospitals, assisted living), ensuring high-quality visits, communication, and care coordination
• Engage in ongoing care coordination, supporting caregivers, and promoting dignity and autonomy in decision-making, including advanced care planning and life expectancy considerations
• Conduct honest conversations with participants and families about care priorities, advanced directives, and end-of-life considerations.
• Focus on avoiding hospitalizations, ED visits, nursing home admissions, polypharmacy, and over-treatment/under-treatment of diseases.
• Act as a resource during the intake of new participants, helping to ensure their care protocols and needs are understood and addressed from the start
• Operate with high emotional intelligence, showing empathy and compassion in interactions with participants, caregivers, and the healthcare team. Actively listen to concerns and respond thoughtfully, ensuring a supportive and trusting environment.
• Exhibit professionalism and emotional intelligence in daily interactions with the interdisciplinary team (IDT) and PACE leadership, promoting a positive, collaborative, and productive team dynamic.
• Support a culture of continuous improvement by being receptive to feedback, fostering professional growth, and maintaining a calm, respectful presence in challenging situations.
• Follow the principles of Just Culture and Psychological Safety, contributing to an environment where open communication, mutual respect, and learning are prioritized.
• Average of 5-7 patient visits a day (up to 8 if needed for acute visits).
• Ensure each participant is seen at least every 60 days.
• See each participant within 7 days of an ED visit (preferably within 3 days), hospital discharge (preferably within 3 days), and SNF or LTC discharge (preferably within 3 days).
• Make efforts to see patients face-to-face before sending them to the emergency room unless its an acute emergency.
• Willingness to see patients in their homes as needed.
• Willingness to see patients via telepresence as needed.
• Focus on thorough documentation and identifying hierarchical condition codes (HCCs), especially early in the year.

Quality / Compliance

5%

• Collaborate with the Medical Director and Clinic Practice Manager to identify needs for clinical practice and workflow improvement that align with evidence-based care.
• Assist with the creation and implementation of quality improvement initiatives and ensure they align with organizational goals.
• Contribute to training staff on medical practices, safety protocols, and geriatric care nuances.
• Participate in quality assurance and safety initiatives to improve participant care and safety.
• Adhere to PACE program quality standards, compliance protocols, and all applicable regulatory requirements.

Professional Development & Other Duties

5%

• Engage in ongoing professional development, including attending relevant seminars and staying updated on best practices in geriatrics and chronic disease management.
• Mentor team members, guiding new staff or learners with respect and encouragement.
• Be open to feedback, continuously striving for personal and professional growth.
• Provide short-term coverage at other PACE sites as needed.
• Support interdisciplinary teams as a resource for clinical decision-making and participant care.
• Perform other tasks as assigned, including but not limited to assisting with administrative duties and quality improvement efforts.
• Provide training and guidance to Immanuel Pathways staff on medical practices, safety protocols, and the nuances of geriatric care.