PA/NP Mobile Integrated Health
South Shore Health
- Weymouth, MA
- Permanent
- Full-time
- Chronic Disease Management through periodic visits
- ED Avoidance Program for acute access to MIH visits to prevent unnecessary ED utilization
- Alternative to Admission for ongoing treatment of acute medical conditions for patients seen in SSH ED
- Early Discharge for patients admitted to SSH who can continue their care plan in the home
- SNF at Home for patients discharged from SSH in need of intensive PT/OT and skilled nursing services in the home, otherwise not available in traditional settings
- Manage a panel of MIH SNF at Home patients
- Conduct MIH Initial Admission Visits with MIH paramedics via telehealth
- Complete medication reconciliation at initial visit
- Conduct twice weekly telehealth visits with patients
- Manage patient clinically during SNF at Home episode
- Interface with MIH Leadership and SSVNA to create care plan for patients on panel
- Responsible for ordering and reviewing any necessary labs or imaging for patients on panel
- Attend weekly MIH SNF at Home Case Conferences (currently Weds 3-4 pm)
- Metrics followed for SNF at Home patients will include:
- ED visits
- Readmission rate
- Average length of stay
- Cost of care per episode