Coordinates case management for members residing in community long-term care facilities. Provides and ensures high quality care to include assessment, evaluation, development, facilitation and implementation of individualized plans of care. Provides consultation and education to other health care providers. Collaborates with special work teams in developing programs to support continuity of care. Provides consultative and clinic nurse specialist/nurse practitioner services for homecare patients. Collaborates with physicians in providing direct primary, secondary and tertiary care services in outpatient, home, inpatient, and community settings with emphasis on long-term care arena.  Liaisons between members/families, clinics, hospitals and selected long term care facilities.

• Provides consultation and direct care to geriatric inpatient, outpatient and home care patients.  Provides primary care and case management to panel of members residing in long-term care facilities which include intake assessment, evaluation, development of individualized plan of care, annual physical exam, timely certifications and recertifications, routine follow-up visits and urgent visits in collaboration with physician to assess, diagnose and implement therapeutic plans of care including prescribing medications, wound care and debridement within scope of practice.
• Encourages and documents advanced directives clarifications. Documents all care provided to patients including observations, treatments, medications and instructions according to Regional and/or facility standards. Documents all communications and medical orders. Completes Kaiser visit logs and required encounter data in timely manner.  Orders and monitors laboratory, radiology and other diagnostic tests. Educates patient and family about health status, prognosis and treatment choices.
• Works collaboratively with hospitals, clinics, and community sites in program development, and development of policies, procedures, quality assessment and improvement indicators for these programs. Identifies needs and coordinates inservice programs, workshops and seminars. Participates in educational program planning, development, presentation and evaluation.
• Acts as liaison with and handles facility/family concerns related to long-term care. Identifies and reports potential problems to appropriate Kaiser Permanente representatives. Participates in patient care conferences with other health care team members to coordinate, discuss and evaluate services provided to patient. Participates in department functions such as staff meetings, staff inservices and committees as assigned. Participates in orientation of new personnel and precepts students as assigned. Represents Kaiser at appropriate community events. Takes call for selected long-term care facilities on rotation with geriatrician and other APRNs.
• May perform patient care to the extent necessary to maintain clinical expertise, competency, and licensing necessary to fulfill job responsibilities and to direct the provision of care on the unit.
• Provides direct patient care on an as needed basis. Provides services that are within scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed.
• Incorporates the KP Nursing Vision, Model and Values throughout their Nursing Practice.