Advanced Practice Provider - Pre/Post Surgical Optimization

Mass General Brigham•Somerville, MA

1d•Hybrid

About The Position

The APP will join a multidisciplinary team dedicated to provision of innovative, patient-centered care as part of the CMS Transforming Episode Accountability Model (TEAM). This is a mandatory, episode-based, alternative payment model, in which Mass General Brigham will coordinate optimal care for traditional Medicare patients undergoing one of five specified surgical procedures and assume responsibility for the cost and quality of care from surgery through the first 30 days after the patient leaves the hospital. This model aims to improve the patient experience preoperatively, through surgery and recovery. This will be done by supporting the coordination and transition of care between providers and promoting a successful recovery that can reduce unnecessary post-acute care utilization and readmissions. This role is designed to proactively assess and support these patients through the full journey of the surgical episode (pre-surgery, in-facility surgery, post-surgery). The APP is responsible for medium- and high-risk pre-operative optimization and provides direct patient care both in-person and virtually. They will work closely with the multidisciplinary team to support patient optimization throughout the course of the episode. The APP also conducts risk capture and risk assessment, as well as closure of quality care gaps.

Requirements

Advanced Practice Registered Nurse (APRN-NP) or Physician Assistant (PA) licensure required
More than 2 years of licensed experience required.
Skilled in taking medical histories to assess medical condition and interpret findings.
Ability to maintain quality control standards.
Ability to react calmly and effectively in emergency situations.
Ability to interpret, adapt and apply guidelines and procedures.
Ability to communicate clearly and establish/maintain effective working relationships with patients, medical staff and the public.
BLS required (or secured within the first 3 months of employment)
al issues efficiently and effectively with minimal supervision

Nice To Haves

Experience in perioperative medicine and/or geriatrics preferred.

Responsibilities

Seek and maintain personal knowledge regarding perioperative optimization and associated problems to provide accurate resource information to patients
Maintain clinical competency, professional skills, and knowledge through experiences and formal continuing education programs and independent learning activities
Responsible for maintenance of all certifications/licensures required to fulfill duties of the position.
Willingness to collaborate with hospital colleagues and outside healthcare resources are essential
Foster communication between TEAM program staff and other health care team members
Participates in the assessment, development, implementation, and evaluation of quality improvement programs, standards of practice, and policies and procedures.
Fulfill duties to ensure seamless patient care as requested by medical director
Other Administrative Duties: as necessitated by program development and at the direction of leadership.
Provide both virtual and in-person direct patient care and education to TEAM patients
Provide support for all clinical needs of the multidisciplinary TEAM program team
Conduct comprehensive pre-operative geriatric assessments and pre-op optimization screen related to mobility, frailty and support at home
Place lab, and DME orders as indicated for TEAM pathways
Enter referrals for imaging as indicated for TEAM pathways
Enter referral to specialists as indicated for TEAM pathways
Document assessment data, orders, interventions, results and evaluations within the patient's medical record per established standards
Documentation is consistently complete, accurate, timely and legible in accordance with departmental policies and procedures
Drive early patient engagement to support safe discharge
Provide clinical oversight of day-to-day team functions (including refinement of protocols, procedures and policies)
Serve as escalation pathway for CMS TEAM coordinators and PT Navigators
Collaborate with local surgical or inpatient teams as indicated
Assist in development and optimization of care pathways, perform PDSA and other process improvement tools
Provide information, education, and support to patients and families; include them in planning discussions, with a focus on discharge home
Respond to ongoing patient questions
Manage additional referrals and pre-op optimization needs
Conduct follow-up engagement as indicated
Elicit goals and values from patients and families to better guide them in care plans
Answers telephone calls/messages from patients, family members and clinical staff
Complete review and documentation of patient conditions in alignment with PHSO risk capture team
Use standardized tools for risk/ discharge destination
Bill for activities via required billing pathway
Compliance with MGB billing standards