The Nurse Practitioner (NP), in collaboration with the PACE Southeast Michigan (PACE SEMI) physicians, is responsible for the medical care of PACE SEMI participants as approved by the Interdisciplinary Team (IDT). The Nurse Practitioner only acts within the scope of his/her practice. The practice parameter for the nurse practitioner is determined by the location of the participant including but not limited to: the PACE SEMI day health center, home visits, hospitals, nursing homes, and assisted living facilities.

• SPECIFIC DUTIES AND FUNCTIONS
  The nurse practitioner assumes responsibility under physician direction for the medical management and planning of participant care.
• The nurse practitioner works and collaborates with all members of the interdisciplinary team.
• The nurse practitioner may perform all levels of practice of a registered nurse, and in addition, the nurse practitioner can perform the following duties:
  
  • Periodic assessments;
  • Physical examinations for acute visits;
  • Assessing for pathological developments and evaluating episodic illnesses;
  • Making referrals to other physicians including specialists with staff physician approval;
  • Providing for and coordinating primary care services needed by the participants, including health promotion and health screening;
  • Offering education to participants, families, and other team members;
  • Coordinates care with other services;
  • Communicates participant changes to the interdisciplinary team in a timely manner
  • Coordinates 24 hour care as indicated by the interdisciplinary team
  • Documents in the medical record each of the above as well as other changes or pertinent information in a timely and accurate manner
  • Facilitates the admission of participants to in-patient facilities, including hospitals, nursing homes, and extended care facilities; and participates in the care planning in those facilities, with staff;
  • Encourages all participants to have Advanced Directives and provides education as needed; may discuss the Do Not Resuscitate (DNR) option with the participant and/or family members and may complete the Health Care Wishes form and write DNR orders in the medical record, in collaboration with a physician and update electronic medical record.
• Assessments done by the nurse practitioner will be completed prior to the participant centered care conference and the care plan will be completed by all interdisciplinary team members at the conclusion of the patient centered care conference.
• In collaboration and consultation with the PACE SEMI physician, the nurse practitioner may diagnose and treat common health problems, which may involve:
  
  • Initiating appropriate diagnostic studies, such as laboratory, x-ray and other specialty procedures with physician approval
  • Adjusting the treatment plan in collaboration with the physician;
  • Instituting emergency medical measures in life threatening situations;
  • Monitoring for changes in participants with chronic diseases or disorders;
  • Transmitting to the pharmacist in writing, valid prescriptions, including controlled substances, Schedule 3- Schedule 5 medications, that the supervising physician has delegated the nurse practitioner to prescribe
  • Following up with participants in the home or in-patient rounding in nursing facilities to evaluate their status; conferring with a PACE SEMI physician in regard to an actual or suspected status change;
• The nurse practitioner participates in committees and activities within PACE SEMI as well as throughout the Henry Ford Health System and at state and national levels.
• The nurse practitioner disseminates knowledge and expertise through professional activities such as conferences and publications and maintains professional certification.
• The nurse practitioner reports administratively to the Medical Director; the nurse practitioner provides after hours on-call medical assistance on a rotating basis via telephone triage or after hours home visits to participants as needed.
• The nurse practitioner must comply with hospital TB testing, infection control, BLS and mandatory in-service requirements.
• The nurse practitioner participates in the DataPACE collection.
• The nurse practitioner acts as a role model for professional nursing practice among his/her peers.
• The nurse practitioner supports and contributes to the development of nursing students as well as students of other health-related disciplines.
• Responsibility and coordination of foot care services.
• The nurse practitioner performs other duties as assigned.

• Registered Professional Nurse, with current Michigan license, and Masters of Science in Nursing with a clinical nursing focus and nurse practitioner license.
• Three (3) to five (5) years of progressively more responsible experience as an RN in a clinical setting with expertise substantiated in the area of geriatrics is preferred, through education, experience and credentials. Must have one (1) year of experience with a frail or elderly population.
• The ability to establish and maintain interpersonal and interdepartmental relationships.
• The ability to apply principles of teaching/learning theories in planning and implementing educational activities.
• The ability to apply principles of research in studying nursing issues.
• The nurse practitioner participates in or facilitates QA projects resulting from data collection results.
• The nurse practitioner participates in various committees within PACE SEMI including, but not limited to:
  
  • Utilization Review Committee
  • Clinic/Primary Care Committee
  • Morbidity and Mortality Committee
  • Advising and counseling the staff nurses regarding program management;
• Supervision of the nurse practitioner will be provided by several methods:
• Immediate, on-site supervision by the PACE SEMI physician;
• Telephone consultation with a PACE SEMI physician who is not on the premises;
• Conferences between the nurse practitioner and the physician regarding medical management, review of charts or any other situation that may arise;
• Chart audits.
• The scope of supervision will depend upon the specific functions the nurse practitioner performs
• The nurse practitioner conducts research projects in accordance with established institutional protocols and in collaboration with other experts in the research or clinical area; he/she integrates the research findings to improve the delivery of nursing care and propose a plan for facilitating a change.
• The nurse practitioner promotes a nursing philosophy that stresses the nursing process and encourages accountability and professional growth of staff nurses.
• Must meet a standardized set of competencies (approved by CMS) before working independently.
• Must be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact.

• Working conditions are variable with exposure to communicable diseases, due to patient environment.
• Driving is required within PACE SEMI catchment area, with possible exposure to extreme temperatures, including heat and cold.
• Frequent walking, bending, lifting of forty (40) pounds or more may be needed in the performance of duties.