UpStream is thrilled to partner with Tidewater Physicians Multispecialty Group (TPMG) across the Hampton Roads areas. Our care teams are embedded in 25+ locations of TPMG Primary Care offices and serve senior patients with chronic disease.

How you’ll help

UpStream’s Coordinating Registered Nurses (CRNs) work closely with patients and the clinical care team members to support the ongoing and coordinated care of UpStream’s patient population. In addition to the CRN, the clinical care team also consists of a Clinical Pharmacist (CP), Enhanced Transition of Care (ETOC) RN, and a team of Health Concierges (HCs), who typically hold a Medical Assistant certification or a practical nurse license.

As an integral member of the care team, the CRN primarily provides high quality care within a remote or clinic setting to support the ongoing and coordinated care of UpStream’s patient population. The CRN serves as the clinical lead for a select patient population who meet predefined, health criteria and works directly with each patient to co-create a patient care plan. In collaboration with the clinical care team and Primary Care Provider, the CRN offers complex care management support aimed at eliminating the burden of chronic diseases. This includes identifying abnormal clinical findings, resolving and preventing critical events, controlling conditions, decreasing avoidable hospital admissions (and readmissions), ensuring safe care transitions, and improving self-management skills.

CRN's contribute to UpStream’s patient-centric, emotionally-intelligent, and relationship-based culture. We seek individuals interested in positively contributing to this culture and growth. This position requires confidentiality, discretion, critical-thinking, and exceptional patient service.

What you’ll do

In conjunction with the Primary Care Team and other members of the clinical care team, the following key services are performed by the CRN.

• Comprehensive nursing and social determinant of health assessment with required EMR documentation
• Disease management of high-risk chronic conditions.
• Assesses patient/family abilities to self-engage and develops individualized patient/family education plan focused on development of self-management skills based on standard care protocols.
• Teamwork and Care Plan items:
  • Close collaboration with the clinical care team to build a Care Plan inclusive of findings from the therapeutic work-up and nursing assessment.
  • Fostering team care by gathering the patients baseline medical and psychosocial risks and creates individualized patient care/treatment plans to be carried out by nurses, pharmacists, health concierge, and/or partners with primary care and specialties.
  • Evaluation of effectiveness of care plan resulting in adjustments and edits to support achievement of personal patient goals.
  • Performs analysis of the effectiveness and appropriateness of patient care plan; and modifies care plan based on assessment and evaluation.
  • Delegation and clinical oversight of the HC staff providing clinical outreach, coordination of care, coordination of community resources, and care gap closure to the patient and family.
  • Plans, develops, assesses, and evaluates care provided to specific patient populations and engages team of HCs to divide workload among team where appropriate.
  • Develops and collects data; analyzes utilization of health care resources, including interpretation and application to case load decision making where appropriate.
• Outreach and health promotion services that are offered predominately via telephone but may require home visit with the patient as needed.
• Coordination of referrals and transitions of care from one provider to another or from one care setting to another to include evaluation of need to escalate level of care setting.
• Ensures accurate medication reconciliation and supports ongoing adherence through patient-specific support. This is done in collaboration with CP on care team when appropriate.
• Facilitation and/or procuring timely access to appointments and services required by patient.
• Patient and family/caregiver education.
• Advocates the completion of living wills and advance care planning and where appropriate begin palliative care consults and/or hospice referrals.
• Communicates clear, complete, and accurate documentation in a health record to ensure that all those involved in a patient’s care have access to information upon which to plan and evaluate their interventions.

General expectations for the CRN

The CRN is an essential role within the Clinical Care team and has the following role expectations:

• Delegation to and clinical oversight of the Health Concierge (HC) staff related to clinical care aspects. Including but not limited to outreach assignments, coaching and feedback related to documentation and patient engagement.
• Hybrid support to the clinical care team which consist of:
  • Attendance in daily and weekly care team meetings.
  • Occasional onsite visit to the primary care office to meet with physicians or patients.
  • Home visits to patients with complex medical or social needs.
  • Telephonic outreaches to patients.

Experience and skills you’ll need

• Registered Nurse with bachelor’s degree or equivalent
• At least 3 years of direct practice experience
• Active Registered Nurse License in the state providing services
• Experience in case management, critical care, emergency care or home health strongly preferred
• Previous experience as a RN Case Manager or in acute care management preferred
• Understanding of population health preferred
• Excellent patient service skills
• Ability to maintain positive attitude and personally connect with patients, caregivers and fellow team members
• Must be able to work independently and interdependently within a team
• Developed analytical and critical thinking skills
• Excellent written and verbal communication skills
• Strong attention to detail
• Must be self-motivated and adaptable to changing processes
• A desire to be part of something bigger than oneself
• Experience with various technology platforms and using multiple electronic medical records
• Adept at using Microsoft 365, including Word, Excel, Outlook and Teams

Location/working arrangements – Primarily remote with occasional field work