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 MetroWest Area. 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.
The position requires a high degree of innovation. The ideal candidate is flexible, independent, and willing to participate in multiple activities while providing support to patients by working with the team. Candidates must have strong communication skills and the ability to converse comfortably with patients and their caregivers.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Provides clinical home visits with homebound patients predominantly in (but not limited to) the MetroWest area
- 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.
- Records physical findings, and formulates plan and prognosis, based on patient's condition.
- 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.
- Performs other duties as assigned.
- Work alongside a patient services coordinator to fully implement the House Call program for both house call visits and virtual visits
o 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.
o This may include hospitals, PCPs, 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 the 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 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.
SKILLS/ABILITIES/COMPETENCIES REQUIRED:
- Professional knowledge: Clinical, healthcare knowledge to enable effective interactions and communications with patients, caregivers, clinicians, and healthcare administrators.
- Time Management: Exceptional organizational skills and ability to prioritize effectively and complete tasks; Flexibility to handle multiple tasks and deadline pressures.
- Highly motivated, independent, innovative, and capable of performing in a complex environment
- Strong sense of initiative and perseverance to carry through to completion of tasks; Demonstrates forthrightness and integrity.
- Ability to identify issues/projects and initiate plans to address asking for direction when appropriate
- Ability to develop a common vision for diverse communities, communicate effectively, and take ownership and responsibility for activities.
- Interpersonal/communication: Excellent interpersonal, written and oral communication, and public speaking skills; Good command of the English language, including medical and scientific terminology.
- Information Systems/Technology Skills: Exceptional computer skills (including operating systems, databases, electronic mail, Internet, spreadsheets, and other office management systems); Ability to maintain databases and associated analysis and reporting.
- Quality Assurance: Skills to work efficiently and effectively and strive to do so in all aspects of the position.
- Critical Thinking/Decision Making: Ability to appropriately evaluate all aspects of a situation and to independently make appropriate and timely decisions.
- Personnel Management: Ability to coordinate among diverse populations.
- Discretion and Confidentiality: Ability to handle sensitive and confidential matters discreetly and to ensure confidentiality guidelines are maintained by staff.
- Safety/Compliance: Knowledge in aspects of safety applicable to the position; Knowledge of and compliance with institutional, JCAHO, HIPAA, and other regulatory bodies' standards.
LICENSES, CERTIFICATIONS AND/OR REGISTRATIONS:
Current licensure in the Commonwealth of Massachusetts.
EDUCATION
- Master's Degree required
EXPERIENCE:
Previous experience as an APP required; Neurology or Palliative specific experience preferred
WORKING CONDITIONS:
- Must be able to and have the means to regularly travel by car for clinical home visits in Massachusetts
- Must have access to the internet, work laptop will be provided.