Nurse Practitioner- Palliative Care

Nurse Practitioner Advanced Illness Management (AIM)

The Nurse Practitioner Advanced Illness Management (AIM) facilitates advanced illness management and palliative care for patients, ensuring a comprehensive, individualized treatment plan, while demonstrating excellent clinical skills and ethical, relevant judgment. Provides diagnosis, treatment, consultation, and follow-up under the direction of the Palliative Medical Director or Primary Care physician.

Job Description

• Work in collaboration with the Professional Services Corporation (PSC) Physician or supervising physician, Primary Care Physician, and other palliative team members to deliver advanced illness management and palliative care by providing diagnosis, treatment, and follow-up for patients referred to the company.
• Take responsibility for advanced illness management from the initial assessment through discharge. Assessment at a minimum should include: disease-specific changes, decline or change in function, nutrition and/or cognition, inadequately controlled pain or other distressing symptoms, falls, infections or similar events, the impact of the disease burden on the patient's condition, caregiver and/or family's quality of life.
• Establish the plan of care, individualized for each patient, in consultation with the patient, family, and other members of the Advanced Illness team, to include the PCP.
• Facilitate obtaining care for patients when a need is identified in accordance with the Plan of Care.
• Participate in evening/weekend call as required, conducting on-call services in a clinically competent and responsive manner.
• Prescribe medications including controlled substances to the extent delegated and licensed, in accordance with state law. Order and interpret laboratory, imaging, and other diagnostic tests within the scope of professional practice. Order treatments and durable medical equipment as indicated.
• Communicate clinical findings to the PSC Physician as needed, but no less than bi-weekly. Re-assess effectiveness of care plan on a regular basis and modify as needed.
• Maintain effective working relationships with supportive care team (e.g., Social Worker and RN Care Manager), as applicable, and involve team (internally and externally) when the patient's care plan warrants team participation to achieve desired outcomes.
• Establish and maintain effective working relationships with those contacted in the course of work.
• Communicate and document clinical findings, treatment plan, and care provided in the patient's medical record in a manner consistent with acceptable standards in order to support sound medical practice and reimbursement for services provided.
• Knowledgeable of Palliative Medicine Quality Measures collection, documentation, and reporting.