Care Home Matron

2 days ago

Boston, United States Massachusetts General Hospital Full time
h3>Job Description

The Amyotrophic Lateral Sclerosis (ALS) House Call Program is an extension of the ALS multidisciplinary clinic at the Healey Center for ALS at Massachusetts General Hospital that is also heavily focused on research both clinical and observational. In 2017, through the establishment of the ALS House Call Program, Mass General was able to take a step forward and provide highly specialized care in our patient’s homes, reducing medical isolation and opening new channels of communication. The House call program Advanced Practice Provider (APP) provides individualized care at home in coordination with the ALS clinic providers.

Under the supervision of the Associate Clinic Director,the ALS House Call APP will work with the ALS clinic team by performing home visits predominantly (but not limited to) the South Shore and Cape Cod regions.In addition, the ALS House Call APP will work closely with the Neurological Clinical Research Institute (NCRI) and ALS Clinic leadership to develop, assess, and implement novel care delivery techniques, including technology-based mobile health solutions, and to more fully integrate ALS care into patients’ lives. The APP will also take the lead in ensuring continuity of care for patients who are unable to travel to the MGH clinic and interact with community and home health providers to more fully integrate care and improve patients’ experience.
Principal Duties And Responsibilities

  • Provides clinical home visits with homebound patients predominantly in (but not limited to) the South Shore and Cape Cod regions
  • Collaborates with the provider (s) to provide targeted healthcare services to patients with motor neuron disease.
  • Performs physical examinations and preventive health measures
  • Develops and implements disease-specific patient management plans, records progress notes, and assists in the provision of continuity of care
  • Assesses, instructs, and counsels patients regarding compliance with treatments.
  • Orders, interprets and evaluates diagnostic tests to identify and assess patient’s clinical problems and health care needs.
  • Prescribes or recommends medications or other forms of treatment such as physical therapy or related therapeutic procedures.
  • Provide home gastrostomy tube exchanges
  • Perform Slow Vital Capacity and Maximal Inspiratory Pressure procedures in the home
  • Complete ALSFRS-R in the home as requested by the primary team
  • Conduct Serious Illness Conversations for advanced care planning and complete the MOLST form to reflect the patient’s wishes
  • Maintains accurate and timely notes in the electronic medical record.
  • Assists physician with comprehensive care
  • Self-directed and purposeful in seeking the necessary knowledge and skills to develop and maintain competency within the specialty of Neurology.
  • Work alongside a patient services coordinator to fully implement the House Call programfor both house call visits and virtual visits
  • Develop and maintain a tracking system to determine program effectiveness, with support from internal data management and IS.
  • Develop and implement systems to standardize Telehealth and Homebound patient care.
  • Explore innovative care models and novel mobile health technology for patients from their homes, reducing the burden on patients to come into MGH, while also increasing clinical care.
  • Collaborates with outside facilities and clinical staff for certain patients, and also provides general information about caring for ALS patients.
  • This may include hospitals, PCP’s, VNAs, Hospice, and private help.
  • Explore innovative ways to disseminate patient and community education materials as a means to enhance continuity of care.
  • Provide support and assistance with challenging patient/physician situations
  • Actively participate in network development initiatives and communicate initiatives back to access team for relationship building within MGH affiliate networks.
  • Participate as requested in MGH and MGB quality initiatives.
  • Participate in various hospital and system committees as assigned.
  • Meets routinely with NCRI and ALS clinic leadership to report on activities, patient satisfaction, problems, and recommendations.
  • In collaboration with the director of the Division of ALS and the associate clinic director, prepares quarterly and annual reports on the house call program to the funding support entities that support the ALS House Call Program.

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