Home Visit Nurse Practitioner or Physician Assistant

About Senior Health:

One Medical Seniors is a network of primary care practices where we take the time to know our patients as true individuals, and proactively provide the care, support, and inspiration they need to live their best life. We created a high-impact relationship based care model that particularly benefits adults on Medicare and those who might need more attention. Our care model changes everything - the team, outcome-focused payment, customer service, and the technology that supports our care. Our practices offer smaller panel sizes, no billing or coding, and the opportunity to lead systemic change in health care delivery while working with a true team. One Medical Seniors wants to restore humanity to healthcare, for both patients and team members.

The opportunity

We are seeking a full-time Home Visit Nurse Practitioner or Physician Assistant to join our One Medical at Home, high-risk home-based care team supporting our patients in the East/Southern Valley of Phoenix (Chandler, Gilbert, Mesa). The Home Visit Nurse Practitioner or Physician Assistant will care for geriatric, frail, and clinically complex patients through a team partnership with the High Risk Care Medical Director, Health Navigators, Care Management Nurses and Social Workers, Integrated Behavioral Health Specialists and practice-based PCPs to provide compassionate human-centric high value care.  

What you'll likely work on

• Live One Medical’s mission of “restoring humanity to healthcare”, for patients and for yourself.
• Rediscover the "joy in practice" while working in a value-based care environment with a team to support you in delivering high quality patient care.
• Once through orientation, independently manage a panel of approximately 150 case mix adjusted patients with multiple, complex conditions through a balance of home visits and telephone/video interventions.   
• Complete thorough initial visits with patients, diving deep into medical, social and behavioral context.
• Work directly with the patient and through the multidisciplinary care team to impact ongoing care with particular emphasis on preventable hospitalizations and ensuring care aligned with patient goals. 
• Your orientation will include opportunities to shadow both home-based and virtual visits, followed by reverse shadowing to ensure a smooth onboarding process. Once you start conducting visits independently, you'll be responsible for in-home or facility visits (such as assisted living, independent living, or group homes) five days a week. After completing at least 90 days of independent home visits and based on performance, you may become eligible to conduct telehealth visits one day a week for scheduled or urgent patient appointments.
• Collaborate and coordinate with the patient's primary care team and specialists. Participate actively in team huddles to review care plans and assess patient goals of care and care plans.
• With support of the team, respond to patient and patient's family telephone calls.
• Participate in the market holiday coverage pool
• Intermittent travel may be required as part of onboarding and/or OM provider development initiatives

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