Advanced Practice Provider- Home Hospital

The Medical Home Hospital Advanced Practice Provider (HH APP) will be part of a clinical team that provides acute-level care to patients in the comfort of their own home. The MGB (Mass General Brigham) Home Hospital (HH) is an innovative strategic service line aiming to improve patient care by shifting it out of hospitals and into the home-based environment, increasing hospital capacity and reducing total costs of care.

The Medical Home Hospital Advanced Practice Provider will support the work of the Home Hospital by evaluating (either in person or virtually) and managing patients in their home as a direct Medical Home Hospital provider, supported by a multidisciplinary team that includes an Attending Medical Provider (who oversees the direction of care for patients enrolled), a Home Hospital nurse, a paramedic (Mobile Integrated Health), an administrative coordinator, and other allied staff as needed (e.g. home health aide, physical therapist, case management). The Medical Home Hospital APP will work with the inpatient and emergency teams at all five participating MGB Hospitals (MGH, BWH, Salem, Faulkner, NWH) to identify patients who qualify for an admission or transfer to Home Hospital service. The HH APP will screen for appropriate patients, communicate with the hospital-based primary teams about appropriate patients, consent patients for admission, and subsequently manage patients on the Medical Home Hospital Service. These patients may originate in the Emergency Department and deemed appropriate for direct admission to Home Hospital or be admitted to the brick and mortar Inpatient services and deemed appropriate for transfer to the Home Hospital Service.

Patients who are admitted to the Home Hospital service will be seen by an admitting HH APP either in the brick & mortar hospital, in person in the patient's home or virtually. The HH APP will be responsible for placing admission or transfer orders to the Home Hospital Service. Daily HH APP rounds will consist of at least one daily patient encounter (in-person or virtual depending on patient needs and clinical course), with medical decision-making and delivery of needed care as appropriate (see specific clinical duties below). The HH APP will facilitate continuity between care settings, ensure home-based and acute care protocols are seamlessly integrated in the home settings, and function as the responding clinician in the home environment.

The ideal candidate for this HH APP role will be a patient-centered, proactive, flexible, experienced, and confident clinician comfortable with autonomy. Must collaborate well with multidisciplinary teams and able to make complex clinical decisions as well as be comfortable with level-of-care triaging, and telemedicine. The role offers the potential to broaden clinical duties as the HH Program expands to other Service lines. This may include involvement with the research & development team creating HH pathways and protocols.

Principle Roles/Responsibilities:

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  Provides acute-level care of medical patients in the home setting (in-person and/or virtual) as a key member of the Home Hospital treatment team (including receiving the patient at his/her/their home, establishing a treatment plan, following Home Hospital protocols where appropriate, acting as a liaison between the home and other care settings, timely clinical documentation, and responding to patient needs with the ability to triage decisions around escalation of care). Other clinical duties may include facilitating in-home diagnostics, point-of-care testing, administration of medications and other treatments, remote patient monitoring, clinical documentation, drain management, wound management, interpretation of diagnostic imaging & laboratory data.

  
  

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  Works with the Home Hospital team members (nurse navigators, coordinators) to identify appropriate patients for transfer/admission to the Medical HH service and completes the admission process.

  
  

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  Establishes relationships with the inpatient Brick and Mortar teams (APPs, medical residents & Attending Providers) at all five MGB sites to help foster seamless transition of care to the HH Service line.

  
  

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  Partners (provides handoff) with the remote overnight HH Nocturnist APPs as they provide cross coverage for all patients on the HH Service.

  
  

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  Collaborates with multidisciplinary Home Hospital team members and patients' longitudinal care team members around appropriate, safe, effective, equitable, and timely care delivery for Home Hospital patients. As well as daily collaboration w/ the Attending of record to ensure closed loop communication about the plan of care.

  
  

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  Communicates with the patient and family about Home Hospital and care plan progression, incorporating patient and family values and goals of care.

  
  

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  Maintains a safe care environment for HH patients and leads in the practice of and reinforcement of a strong safety culture among all clinical partners involved.

  
  

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  Attends relevant team and other meetings related to Home Hospital and related work.

  
  

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  Participates with quality measurement and/or quality improvement initiatives, as appropriate, to advance the work of Home Hospital and other alternative care pathways, including advancements or innovations within the electronic health record.