Advanced Practice Provider Lead - Transitions of Care

Overview

JOB SUMMARY
Under the supervision of the Associate Director of Post Acute and Care at Home Programs (MD/DO), the Lead Advanced Practice Provider (APP) - Transitions of Care (TOC) is responsible for direct patient care for low-income and uninsured patients in post-acute environments as appropriate, including Skilled Nursing Facilities (SNFs), and the Care at Home program (home visits).

The Lead APP-TOC will work in conjunction with Nurse Case Managers, Social Workers, Community Health Workers, Pharmacists, Physicians and other care team members to provide transitions of care/navigation services, working in collaboration with inpatient care teams and other Central Health medical and case management teams. As with other providers in the department, the Lead APP-TOC will coordinate with primary care providers, and other providers in the hospital, post-acute, outpatient, and community settings.

The Lead APP-TOC will also have the opportunity for programmatic development within the Department of Transitions of Care. As the Lead APP, this position will supervise and manage other APPs in the Transitions of Care Department, and provide clinical direction, education, and support. They will collaborate with the TOC Director, Associate Director, and Lead Physicians, TOC Director of Nursing and Associate Director of Nursing, and Nurse Managers, as well as TOC Operations leadership.

The Lead APP-TOC will advocate and liaison for all TOC APPs. Administrative time will be inclusive of leadership meetings (distributed across the week based on meeting times) and other administrative duties. This will include protected decrease in patient census/admissions and dedicated protected time during the week for additional duties as assigned by team (10%).

Central Health's mission is to care for those within the county who need healthcare services and to improve the health of our community. Mission alignment and empathetic approach are central to our goal of advancing health equity and inclusion. This position models a commitment to the organization's mission, vision, and values to support an unparalleled patient experience and positive clinical outcomes.

Essential Functions

• Provide direct patient care to patients in Skilled Nursing Facilities (SNFs) and the Transitional Care at Home program.
• Collaborate with the case management teams across the Central Health Enterprise to coordinate patient care.
• Collaborate with attending physicians to provide care at SNFs.
• Participate and lead quality and care review meetings for patients in the post-acute program.
• Facilitate collaboration with partner organizations to ensure the provision of compassionate, and effective care coordination for hospitalized patients and medical care to other patients in post-acute settings who require medical service.
• Work in close consultation with the patient’s primary care provider and other licensed health care facility providers to deliver medical care of MAP patients while admitted in post-acute environments in the best interest of the patient and consistent with Central Health’s policies, mission and goals.
• Communicate effective information to patients, families, colleagues, nursing and other health care professionals, as appropriate.
• Prepare and provide necessary timely and accurate reports and forms, as may be required by Central Health or facility in the performance of medical services.
• Coordinate care with skilled nursing facility team members and other Physicians and Advanced Practice Providers to eligible patients in skilled nursing facilities.
• Plan and coordinate care daily with all members of Central Health’s care team to assure maximum quality and efficiency of care between Eligible Patients, Physicians, Advanced Practice Providers, case management and nursing.
• Perform medical and administrative services under general guidance and minimal supervision with accountability for specific organizational-level goals.
• Work closely with families of diverse patient populations.
• Facilitate effective communication with Case Management/Care Coordination teams regarding readmission prevention.
• Proactive collaboration to facilitate…