Feltin’s Approach to Primary Care

We deliver home-based person-centered primary care services to people with complex medical needs. We are passionate about expanding access to primary care for people who have difficulty getting served within traditional models of care. We promote autonomy and independence and honor the uniqueness of each person we follow. Our care plans prioritize quality of life, dignity of risk, and patient goals while minimizing disruption and dislocation whenever possible. We schedule regular follow-up visits to address new issues as they arise in order to mitigate the need for urgent care, ER visits, and hospitalization. We value care coordination, interdisciplinary teamwork, and collaboration with all members of a patient’s care team.

Position Overview

The nurse practitioner provides comprehensive in-home primary care and care management services to patients and serves as the primary lead that drives care coordination and care plan development on a team of interdisciplinary care providers that may include nursing, behavioral health, social work, peer support and care navigation roles. The nurse practitioner liaises with all members of a patient’s care team including but not limited to family members, human service org advocates, specialists, and home health services to ensure that care is coordinated and in line with the patient’s goals. The nurse practitioner conducts initial intake, gathers history, performs exams, develops care plans, and drives decision making on complex patients and delegates various tasks and functions to other licensed professionals and team members as appropriate.

This role will primarily serve the Merrimack Valley area (Lawrence, Haverhill, Methuen) with occasional travel to Boston to provide backup coverage as needed. Fluency in Spanish is strongly preferred as a large majority of the patient panel will be Spanish speaking.

Essential Duties and Responsibilities

• Provide preventive care services including routine screenings, blood draws, vaccinations, annual wellness visits and physical exams

• Perform triage for new issues that arise; conduct same or next-day visits as needed

• Conduct diagnostic testing in the home as needed, such as phlebotomy and EKGs

• Prescribe medications, process refills, and conduct medication reconciliation as appropriate

• Manage a panel of about 60-100 patients depending on complexity, geography and composition of interdisciplinary care team

• Make referrals to specialists in areas requiring deeper expertise

• Complete documentation and process paperwork related to orders for home health, durable medical equipment and group home care plans

• Provide expert-level clinical documentation in EMR system to accurately reflect complexity, history, and whole-person assessment and treatment

• Adhere to quality measures standards, review metrics and take action to modify clinical approach or decision-making as appropriate

• Participate in continuing professional development and formal CME courses to advance knowledge base and build deeper expertise to maintain required licensing and credentialing requirements

• Support interdisciplinary team colleagues by mentoring new and existing staff, and offering teaching opportunities when applicable

• Seek opportunities to expand capacity by identifying ways to streamline key functions, delegate where appropriate, and suggest tech solutions that foster increased efficiency

• Collaborate with administrative personnel as needed when clinical expertise or judgement is needed in administrative, financial, or strategic decision making.

Requirements

• Graduation from an accredited NP or PA program

• ANCC or AANP (for NP) or NCCPA (for PA)

• Fluency in Spanish

• Master’s degree in Nursing or PA degree

• Licensure to practice in the state of MA

• Mass Controlled Substance Registration

• DEA Registration

• 2-5 years relevant experience as independent NP

• Valid MA driver’s license, use of own car and up to date auto insurance plan

• Position is home-based but use of personal car throughout the day is required to make home visits, pick up vaccines/supplies and drop off lab specimens.

Desired Skills and Knowledge Base

• Ability to operate independently and make numerous clinical decisions everyday utilizing physician curbside consult in areas with greater complexity

• Demonstrates excellent clinical judgement, and a curiosity for deeper understanding in areas with less expertise

• Collaborates well with colleagues in close-knit team setting

• Must be comfortable working with patients who have a complex array of conditions including behavioral health issues or psychiatric disorders, developmental or intellectual disabilities, physical disabilities including paraplegia and quadriplegia and multiple chronic conditions

• Excellent organizational skills and ability to juggle a vast array of tasks with varying levels of priority, complexity, and time requirements

• Proficient use of EMR system, Microsoft Office products, VOIP phone system and comfortable using mobile application equivalents when visiting patients in their homes

• Comfortable going into patients’ homes and delivering care in the home setting

• Proficient at triaging clinical issues and adept at prioritizing competing needs for treatment

• Demonstrates a commitment to healthcare justice for people who have limited access to appropriate primary care

• Experience as an advocate for marginalized and vulnerable people is a plus