PA/NP Mobile Integrated Health - South Shore Health

Job Description Summary

Under the general guidance of the MIH/Hospital at home Medical Director and the Executive Director of APCs, the Nurse Practitioner/Physician Assistant will evaluate, diagnose and treat patients following written guidelines approved by the Department of Medicine.

Job Description

SSH MIH SNF at Home Program

Since the launch on March 4, 2020, South Shore’s Mobile Integrated Health (MIH) program has provided SSH the flexibility to care for patients in the community.  To date, MIH has enrolled more than 400 patients, completed more than 2000 home visits.  Additionally, MIH has tested over 900 non-ambulatory patients for COVID in the community.  During the initial wave of COVID, MIH was able to support the inpatient platform at SSH by caring for  COVID + patients in the home, most admitted to the program directly from the ED.

MIH currently offers a variety of levels of care including:

• 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

The SNF at Home program is a combined effort between MIH and SSVNA to provide SNF level of care to patients in the home as an alternative to a traditional brick and mortar SNF.  When enrolled in the program, patients are scheduled for an MIH Admission Visit within 48 hours of hospital discharge or referral.   They are then followed closely by MIH Providers and SSVNA, with intensive PT/OT services, skilled nursing and twice weekly provider telehealth visits.  As MIH continues to grow and expand, we are looking for SSMC providers who may be interested in participating in the program by becoming an MIH SNF at Home Provider.

MIH SNF at Home Provider Job Description

• 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