Administratively Reports to: ARMS CEO or designee
Collaborates with: ARMS Physicians who round at Nurse Practitioner’s Facility(ies)
- The Post-Acute and Long Term Care Nurse Practitioner (PAC-LTC NP) is a masters or doctorate prepared Nurse Practitioner.
- The Nurse Practitioner must have a valid Indiana license as a Registered Nurse and as a Nurse Practitioner and be certified as an Acute Care, Adult, Geriatric or Family Nurse Practitioner by an approved certifying body.
- Experience in caring for acutely ill patients with complex medical and surgical conditions preferred, as well as comfort and experience with patients with multiple chronic medical conditions.
- Current DEA certificate for Schedule II-V drugs and state CSR.
- BLS and ACLS certified or willingness to obtain prior to start with ARMS.
Note: The information below is not intended to be a complete of responsibilities, but provides an outline of major functions and expectations.
The PAC-LTC NP functions within both the Skilled Nursing Facility (“SNF”) setting and the long term care (“LTC”) environment (including “Memory Care”) as well as providing primary care to residents in Assisted Living (“AL”) settings. She/he works in collaboration with multidisciplinary health care teams. The PAC-LTC NP demonstrates a strong foundation in evidence-based practice and education and encourages an environment that provides high quality, compassionate, patient-centered, safe care. The PAC-LTC NP must demonstrate high levels of medical and nursing knowledge that translate into technical and clinical competence and must exhibit professionalism in all interactions, whether with staff members at the Nursing Facility, patients/residents or family members. The PAC-LTC NP also shares in on-call responsibilities, providing timely, helpful response to texts and phone calls from Nursing Facility staff.
While the PAC-LTC NP is generally assigned to a specific facility or facilities, there may be times when she/he is asked to provide temporary coverage at other facilities due to staffing requirements or in times of low patient census at her/his primary facility.
Key Function #1 Assessment, Diagnosis, Treatment and Plans of Care
The PAC-LTC NP coordinates with rounding physicians to ensure that each patient admitted to the SNF or LTC setting (including AL) receives a comprehensive health history and physical examination, appropriate diagnosis(es) and a plan of care which can be communicated with the patient and other team members.
- Performs and documents a complete H&P appropriate to the patient’s level of illness and complexity. (In the SNF environment, this evaluation serves as a “tuck in” visit. In the LTC setting, it can serve as the definitive H&P.)
- Formulates differential diagnoses and evaluates new problems.
- Addresses care of patient’s acute and chronic medical problems, including the development of problem-specific assessment and plan.
- Writes appropriate orders, including diet, diagnostic testing, and evaluations an consultations
- Follows up on diagnostic tests
- Assesses patients’ nutritional, behavioral health, and preventive service needs.
- Ensures regular visits and all acute visit are performed appropriately with regard to regulatory compliance and medical necessity.
- Incorporates patients’ desires into plan of care, including but not limited to,
- Goals of rehab stay or plan of care for acute/chronic problems for LTC patients
- Advance directives or other end of life wishes, when appropriate
Key Function #2 Involvement with Discharge/Transition Plan for SNF Patients
The PAC-LTC NP plays a key role in transitioning patients’ from the SNF rehab environment to their next level of care, whether a higher level due to a return to acute care, or to a lower level such as home with home health or residential LTC. In some cases, the PAC-LTC NP may have responsibilities for the same patient population as they return for additional outpatient follow-up.
- Coordinates with discharge planning team, patients and families, to determine the best transition for patients
- Records a discharge examination and prepares complete discharge paperwork to provide communication to the next care provider
- May provide patient and/or family education regarding plan of care at discharge, acute and chronic conditions, and medication usage and possible side effects
Key Function #3 Communication, Documentation and Professional Practice
The PAC-LTC NP represent ARMS as a company and her/his collaborating physicians, as well as the medical/nursing professions at all times while providing services.
- The PAC-LTC NP remains in active, ongoing communication with the multi-disciplinary care team, collaborating physician(s) and patients/families. She/he encourages questions and elicits concerns to ensure alignment of all parties involved in patient/resident care.
- The PAC-LTC NP documents completely and promptly in order to communicate plans of care, ensure regulatory and billing compliance, and capture clinical acuity.
- Demonstrates professionalism in all respects, including, but not limited to:
- Prompt and appropriate responses to staff and patient/family questions and concerns
- Documentation that is free from “editorials” which are not germane to patient care
- Ongoing support for the facility’s (-ies’) quality improvement and patient safety programs
- Membership in at least one professional organization that is pertinent to his/her work as PAC-LTC NP
- Ongoing continuing education supportive of work in the post-acute setting
- Willingness to accept constructive feedback
- Educate nursing staff at facility (ies) to improve nursing improve patient outcomes.
- Provide leadership at facility(ies) in the development of evidenced-based policies, procedures and protocols, and best practice models/guidelines.
Key Function #3 Involvement and Support of ARMS
The PAC-LTC NP is an integral member of the ARMS team. She/he supports ARMS and collaborating physician(s) in several ways, including, but not limited to the following:
- Supports Corporate Compliance with regulatory, billing, and other standards
- Participates in ARMS provider meetings with regularity.
- Embraces change as the ARMS care model and the facility(ies) evolve to meet the needs of the post-acute and LTC populations.
- Remains up-to-date regarding Indiana-code relative to PAC-LTC NP scope of practice
- Participates in Community Outreach and Physician/Provider Liaison services on behalf of ARMS and her/his assigned facility(ies).
- Mentors and orients new PAC-LTC NP’s during normal workday hours.
- During times with low census, PAC-LTC NP may be asked to help in development and/or review of clinical policies, procedures and educational materials.