Toolkit for Implementing the Chronic Care Model in an Academic Environment
Nurse Practitioner Job Description
Adopting the Chronic Care Model may entail redefining roles. The Summa Health System Change Team positioned the nurse practitioner as the collaborative care manager, using the following job description.
Nurse Practitioner for Collaborative Management Model
Summa Health System Department of Medicine
Collaborate with attending physician(s) from Summit County Internists and Associates, Inc. (SCI) to provide assessment and clinical management of patients. The Nurse Practitioner will provide recommendations and serve as a resource for the development of patient care standards, clinical decision-making, protocols, and procedures related to nursing practices for SCI. Job specifications related to the Nurse Practitioner's area of practice are outlined in the attached addendum as appropriate.
- Master of Science in Nursing degree.
- Appropriate certification as a Nurse Practitioner from an accrediting body with (1) year post masters experience in clinical practice.
- Valid Certificate of Authority for Advanced practice Nursing in the State of Ohio.
- Valid Certificate to Prescribe or eligibility to apply for prescriptive privileges in the State of Ohio within 6 months of date of hire.
- Current RN license to practice nursing in the State of Ohio.
- Maintain continuing educational requirements as determined by Ohio State Board of Nursing and credentialing body for advanced practice certification (i.e., American Nurse Credentialing Center)
- Obtain patient histories, perform physical examinations and identify normal and abnormal finding and develop an appropriate treatment plan.
- Evaluate and manage acute problems and changes in status.
- Operationalize the patient's plan of care and perform patient rounds as needed.
- Perform procedures related to scope of practice and clinical specialty.
- Order and interpret diagnostic tests.
Educational and Faculty Responsibilities
- Provide leadership in planning, implementing, and evaluating new programs of care in addition to re-appraising and improving existing programs for SCI. This includes research and quality assurance activities.
- Provide consultation and education to medical resident, graduate nursing students, and nursing staff regarding patient care issues.
- Provide patient education.
- Utilize community resources and act as a liaison by relaying information necessary for continuity of care to other professionals and agencies.
- Attend and participate in pertinent meetings associated with SCI.
- Review Standard Care Arrangement at a minimum of once a year. In addition, Prescriptive Practice will be reviewed at least semi-annually and initialed on the standard care arrangement.
- Maintain affiliated hospital privileges as an Allied Health Professional.
Nurse Practitioner Collaborative Care Manager
- Supervise and participate in the medical management of diabetes planned visits. This includes patient care as defined in the Clinical Practice section and collaboration with an interdisciplinary team.
- Provide care management for the patients. This includes office visits, group visits and phone management.
- Educate patients as part of the group visit using the American Diabetes Association curriculum. Schedule, manage and assist invited speakers and interdisciplinary team members. Complete one on one medical assessment and treatment as part of the group visit.
- Train residents on the chronic care model, intensive medical management, interdisciplinary care and the use of algorithms for the diabetic patient.
- Collaborate with the patient's physician, the, clinical expert (endocrinologist), the staff and all involved team members as needed for comprehensive patient care.
- Participate in interdisciplinary team meetings and assist with implementing interventions as needed.
- Update patient registry with any changes. Use this registry to monitor care.