Fallon Health Nurse Practitioner - Growing Elder Services PACE Program - Worcester, MA in Worcester, Massachusetts
SUMMIT ELDERCARE ()
Fallon Health’s – Summit Elder Care program one of the largest PACE programs (Program of All-Inclusive Care for the Elderly) in the country and the very first PACE program in the nation to be associated with a Health Plan. Summit ElderCare currently already serves residents of Hampden County, Worcester County, and the communities of Easthampton, Granby, Hudson, Marlborough, Southampton and South Hadley. We help give elderly adults and their caregivers an innovative choice in health care as a welcome alternative to nursing home care. Participants in Summit ElderCare have access to most medical services through a Summit ElderCare site while they keep living in their own homes and communities.
About Fallon Health :
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit.
Provides primary health care to Summit ElderCare program participants focusing on disease prevention and/or stabilization, and management of chronic and episodic illness in collaboration with the program’s primary care physician providers. Works with the interdisciplinary team to establish realistic and measurable goals and to develop and manage individualized plans of care for program participants.
Performs initial and periodic comprehensive assessments of participants for the purpose of developing complete lists of medical diagnoses and plans of care, in collaboration with SE physicians
Evaluates participants with new symptoms or episodic illnesses and orders appropriate treatments and interventions
Performs routine monitoring of chronic illnesses
Performs those interventions identified in the Interdisciplinary care plan as appropriate for the PCP and/or NP
Participants in Interdisciplinary team meetings
Visits and provides assessments and care for SE participants in their homes, in Skilled Nursing Facilities, and in the SE Centers. Visits participants in acute care settings as appropriate to help with treatment decisions and discharge planning
Documents all care and services in succinct and accurate ways consistent with professional standards
Establishes and maintains effective working relationships with program participants, family caregivers, medical staff, and program staff
Participates in provider Chart reviews as requested by the medical director or associate medical director
Recognizes, identifies, and implements opportunities to help meet Utilization goals
Supports the fundamental mission of the Summit ElderCare program
Participates in quality assessment and performance improvement projects and workgroups
Education: Masters Degree in Nursing and a graduate of an accredited Nurse Practitioner program. Maintain (and further develop when appropriate) competency in clinical practice through self study and attendance at educational programs.
License/Certification: Licensed by the Commonwealth of Massachusetts Board of Registration in Nursing as a NP. National Board Certification as a Geriatric, Adult, or Family Nurse Practitioner
Experience: Three or more years of Nurse Practitioner experience in both an office setting and a long term care setting preferred, Previous experience with an interdisciplinary
approach to care management. Facile with Electronic Health Records.
Job ID 5576
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