Family Nurse Practitioner

Position Overview:  Family Nurse Practitioner (FNP) to provide full-spectrum care for individuals experiencing homelessness. This unique role combines direct patient care at a homeless shelter one day per week with a liaison function between hospitals and shelters for the remaining time. The goal is to reduce disease burden, prevent avoidable hospitalizations, improve patient outcomes, and minimize emergency room (ER) bounce-back visits.    

Reports to: Agency Medical Director

   Essential Functions: 

• Hospital-Shelter Liaison  
• Serve as the key communication link between hospitals, emergency departments, and homeless shelters to ensure seamless transitions of care. 
• Assist in discharge planning to reduce hospital readmissions and ER recidivism, including going onsite to hospitals as needed. 
• Coordinate follow-up care, social services, and medication access for patients post-hospitalization. 
• Educate shelter staff on managing common medical conditions and recognizing signs of health deterioration. 
• Advocate for patients by addressing barriers to care, including transportation, insurance, and social determinants of health. 
• Run reports as needed from agency databases for grant reporting purposes. 
• Render to patients medical services normally expected of a family practitioner in office practice: Examine, diagnose and treat medical illnesses, evaluate health status, initiate therapeutic and preventive measures, and make appropriate and necessary referrals to specialty and other consultative medical services. Those medical illnesses which are treated include the entire spectrum of family medicine. 
• Carry a patient caseload consistent with quality of care and productivity standards. 
• Communicate on an ongoing basis with other health care providers and other staff on all aspects of the health needs of patients. 
• Complete all necessary paperwork connected with duties, including progress notes in the medical records, completion of all forms required by the data collection system of medical center and all outside reimbursement and regulatory agencies and organizations. 
• Attend medical staff meetings and conferences as required. 
• Maintain professional competence through participation in outside conferences, and other continuing medical education activities. 
• Participate in teaching BRC staff by imparting understanding of the rationale and methods of diagnostic and therapeutic activities on the job on an on-going basis, and when requested, in a more formal manner. 
• Under appropriate circumstances, and with the approval of the Medical Director, admit patients to hospital and perform the normal duties of an attending physician in the management of patient care. 
• Participate in after-hours telephone triage one week a month. 
• Assist in peer review chart audits and other appropriate quality activities. 
• Supervise the patient care activities of BRC staff assigned to work with him/her in patient care. 
• Provide care to patients with acute or subacute medical problems. This responsibility includes the recognition of acute symptoms, management of emergencies, detection of abnormal findings on physical assessments, reporting of findings, and clinical decision making. In collaboration with supervising physician, provide routine treatment based on policies, protocols, and practice agreements appropriate for licensure for treatment of acute medical problems. Provide appropriate information to patient. 
• Provide care to patients with chronic disorders. Initiate requests for indicated diagnostic tests, begin appropriate pharmacological therapy, make adjustments in prescribed medication as needed, monitor compliance with treatment plans, and ensure continuity of care. Provide direct nursing treatments, administration of medications, and other nursing services as needed. 
• Develop and implement a plan of care for each patient, including additional diagnostic studies; treatments, including prescribing medications within protocols under physician's supervision; referral to other health care providers and for social services; teaching, counseling, and assisting patients and other involved persons to assume responsibility for self-care, prevention of illness, and promotion of health; document and complete all patient encounters and follow-up in a timely manner in accordance with agency and regulatory policy; follow-up to assure continuity of care. 
• Participate in on-going session with supervising physician regarding medical care responsibilities. 
• Assist in developing procedures and protocols for patient care. 
• Work a