Nurse Practitioner, House Calls Program (MI MSO)

Title: Nurse Practitioner, In-Home Care (Michigan MSO)

Role Description

The House Calls Nurse Practitioner delivers high-touch, high-quality, home-based primary care to the highest risk patients. Our NP's lead a cohesive team of Oakies to provide wrap-around, comprehensive, in-home support and care. NPs, along with their Medical Assistant/Scribes, make 4-6 visits daily in a defined territory and collaborate continuously with other team members for care coordination, social services, and behavioral health care. Provider teams enjoy easy access to clinical support from peers and medical directors, tailored clinical education for in-home providers, and dedicated non-clinical time for panel management and patient discussions, using best in class population health data. This is a traveling position that provides in-home primary care to medically complex seniors.

Program Overview

The House Calls Program (known as @HOME) delivers high-quality primary care to Medicare patients in their home. The @HOME program takes a team-based approach to providing outstanding patient care. Our Care Teams - consisting of a Provider, Medical Assistant/Scribe (CIS/MA), Behavioral Health Specialist (BHS) and Mobile Operations Coordinator (MOC) - build individual relationships across a small panel of patients, seen monthly. The Care Team is responsible for delivering excellent, high-touch primary care, and coordinating the care of patients.

Core Responsibilities

• Provide longitudinal care to high frailty patients according to defined pathways within the patientient's home

• Develop care plans and individualize goals of care with patient and families

• Optimize and monitor clinical status, identify and address gaps in care, reconcile medications and address adherence challenges

• Collaborate with home health, specialists, social workers, hospitals, SNFs, and specialists

• Structure and prioritize scheduling based on clinical complexity for both new and routine patients

• Recognize, diagnose, and manage both acute and chronic medical conditions

• Facilitate and conduct goals of care and advance care planning discussions with patients and families

• Assess and evaluate family / caregiver needs and limitations

• Teach patients, caregivers, and others about their health conditions

• Embrace Oak Street Health care and risk model, including clinic workflows that support panel health and accurate coding

• Accurate and timely documentation of patient encounters in Oak Streetâ s electronic medical record

• Champion compliance and dissemination of policy, including HIPAA, Patient Identification, and Incident Reporting

• Other duties, as assigned

What are we looking for

• Genuine passion for primary care and reaching vulnerable patients

• Strong clinical skills focused on older adults with complex disease states

• Comfort navigating visits in patient homes

• Demonstrated ability to collaborate effectively in a team setting

• Willingness to learn and be accountable for visit documentation and workflows

• Excellent communication, follow-up, teamwork, and problem-solving skills

• Desire to be a part of a fast-paced, innovative, quality-driven organization

Required Qualifications

• Have an active, non-probationary state medical license, including US work authorization, if applicable

• 1+ years APN experience, preferably with a Medicare population

• Experience in home-based care (as RN or APN) preferred

• Flexibility to travel throughout service area

• Electronic Medical Record experience

• Computer skills: Ability to quickly navigate and use multiple computer programs to include, but not limited to: Gmail, MS Word or Google Docs, Excel or Google Sheets, etc.

• Additional language proficiency in Spanish, Polish, Russian, or other languages spoken within the communities we serve preferred but not required