The Nurse Practitioner (NP) Home-Based Primary Care (HBPC) is accountable for the management and
evaluation of a panel of patients under his/her care in the participant’s home. The NP HBPC provides
comprehensive preventative and wellness care, as well as the spectrum of acute, episodic, chronic, and
end-of-life care to participants assigned to him/her.
The Nurse Practitioner (Home-Based) Primary Care is prepared in advanced practice across the health
continuum. This role includes participating in and use of research, development and implementation of
health policy, leadership, education, case management and consultation. The HBPC Nurse Practitioner
utilizes preventative clinical guidelines and appropriate standards of care in collaboration with the Homebased Primary Care Medical Director and Team Physician in providing holistic quality care to patients
with complex chronic and acute on chronic health conditions with a focus on self-management,
prevention, and wellness, based on the patient's goals.
The Nurse Practitioner is directly responsible to the Director of Community Integrated Programs and must follow local
policy regarding a collaborative agreement with a qualified physician. Utilizes advanced practice nursing
skills and knowledge in a relatively independent manner in areas of patient care, education, research and
consultation.
Education:
- Possess a Registered Nurse License in the State of Michigan
- Must be a Licensed Nurse Practitioner in Michigan.
- Maintain full and current certification as a nurse practitioner from the American Nurses
Association or another nationally recognized certifying body.
Experience:
- Communicate and interact appropriately and courteously with all internal and external customers.
- Maintain confidentiality of electronic, written, and/or verbal patient/employee information
- Demonstrate working practices that include adherence to Infection Control standards and the
safe use and operation of equipment.
- Demonstrates leadership in delivering and improving holistic care through collaborative strategies
with others.
- Utilizes critical judgement in the performance of comprehensive health assessments, differential
diagnosis, and the prescribing of pharmacological and non- pharmacological treatments in the
direct management of patients with complex acute and complex chronic health conditions
5-day work schedule; three (3) days minimum in office, with the flexibility of working
remotely on the remaining days, and/or reporting to the office for business continuity as needed.
Essential Duties and Responsibilities
- The Nurse Practitioner (Home-Based) Primary Care conducts a comprehensive assessment of
patients' medical, physical, and biopsychosocial status including:
- Obtains a relevant health and medical history.
- Performs a physical examination based on age and history.
- Conducts preventative screening procedures based on age and history.
- Updates evaluation of health status to determine need for further health care.
- Formulates appropriate medical diagnoses based on data obtained.
- Orders appropriate diagnostic procedures and laboratory tests
- Identifies and prescribes appropriate pharmacological and non-pharmacological agent.
- Provides relevant patient/family education.
- Consults with collaborating health care professionals when doubt exists as to the diagnosis, when
expected improvement is not soon apparent, and when specialized therapeutic or diagnostic
techniques are indicated.
- Determines the effectiveness of the plan of care through documentation of outcomes.
- Reassesses and modifies the plan as necessary to achieve medical and health goals.
- Performs any procedures for which she/he has been credentialed.
- Performs medication reconciliation in home settings.
- Formulates multi-disciplinary treatment plans.
- Responds to telephone calls from patients and caregivers regarding health care.
- Refers patients to appropriate community programs and medical subspecialties as necessary.
- Other clinical duties as assigned which may include coverage of other HBPC providers.
- Participates in weekly team meetings and provides innovative management ideas for patient case
reviews.
- Participates in continuing program assessment and process improvement.
- Participates in collecting and collating data required for team reports.
- Participates, directs, and provides opportunities for staff development through in-service
education as needed.