Landmark Health was created to transform how healthcare is delivered to the most medically vulnerable members in our community. Our medical group provides home-based medical care to chronically ill patients, many of whom are frail, elderly and ill-equipped to navigate our overwhelming healthcare system.
Because many of our patients are frail and elderly, we deliver care primarily in the comfort of their home. Our Program is also offered to eligible patients . We are not a fee-for-service practice; we benefit economically only if we deliver high-quality patient outcomes and satisfaction. As a result, our clinical teams can spend quality-time caring for a smaller number of patients, giving all patients the space, respect, compassion and care they deserve.
Our model is finding success throughout the country; we are now the nation’s largest risk-based, in-home medical group.
At Landmark, our interdisciplinary teams collaboratively manage our complex patient panels. These teams are led by Physicians, Nurse Practitioners, and Physician Assistants, with supporting care provided by RN Nurse Care Managers, Social Workers, Pharmacists, Behavioral Health and other employed team members.
The Nurse Care Manager (NCM), is an integral part of the Interdisciplinary care team (IDT), and is responsible for the overall care management process for high acuity engaged Landmark patients. The NCM has oversight for developing patients’ plan of care, providing education, guidance and support. Professionals in this role elicit input from the IDT based on initial comprehensive and ongoing assessments of the patient.
The NCM uses nursing assessment and evaluation skills to help guide treatment and care decisions of the team and identifies services and vendors for needed care while navigating patient benefit plans. The NCM works collaboratively with a multidisciplinary team to provide supportive care to enrolled patients. The IDT multidisciplinary team consists of the PCP, specialists, behavioral health clinicians, mid-level practitioners, pharmacist, nutritionist and social worker and the patient, family and/or caregiver.
The NCM ensures that medical services are managed in the most effective and appropriate health care setting according to the patient’s medical condition. The plan of care addresses the clinical condition and psycho/social needs to maximize his/her level of functioning and establishes and maintains communications with all parties.
• Acts as an advocate for the patient in all activities including nursing assessments, care coordination, care plan development, and communication
• Completes an initial and ongoing patient assessment, including a medical record review where available
• Documents current advance care directive status and ongoing efforts to reconcile patient/caregiver goals with the current clinical status
• Initiates and maintains ongoing communications with clinicians and primary care physician
• Engages with families/responsible parties to collaborate on plan of care and discussion of the ongoing management of the patient’s condition
• Coordinates care needs are met across the continuum of care delivery model, as the point of contact for patient/caregiver and clinicians
• Acts as liaison between providers, nursing facilities, hospitals and program staff, including making recommendations about care alternatives or equipment that will aide in the safety of the patient while promoting optimal clinical outcomes
• Monitors patient progress against plan of care goals with an emphasis on patient care needs during transitions and health changes
• Monitors patient during admissions and provides nursing/assisted living facility and provider training on program philosophy and approach to patient care
• Educates patients and/or families/responsible parties on disease processes and ways to manage disease progression as independently as possible
• Identifies and reports any quality-of-care issues and maintains HIPAA compliance as it relates to patient care
• Current RN License is required, BSN is preferred
• 1+ years of utilization management experience preferred
• 3+ years of clinical practice in a hospital, clinic, home care, or nursing home setting highly desired
• Case management experience highly desired
• Disease management and/or physician office experience desired