Advanced Practice Provider-Mobile Integrated Health Program

The Mobile Integrated Health (MIH) Advanced Practice Provider (APP) serves as a key clinical provider within an innovative, community-based care delivery model designed to improve coordination and outcomes for medically complex patients. The APP provides comprehensive assessment, treatment, care coordination, and transitional care services in patients’ homes, residential settings, and other community locations, while collaborating closely with physicians, nurses, care managers, social workers, paramedics, and community partners.

The APP delivers high-quality, patient-centered care that supports hospital avoidance, reduces unnecessary emergency department utilization and readmissions, and promotes patients’ ability to safely remain in their homes and communities. The APP utilizes evidence-based practice, advanced clinical decision-making, telehealth technology, and interdisciplinary collaboration to manage acute, chronic, and transitional care needs.

Brown University Health employees are expected to successfully role model the organization’s values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.

Conduct comprehensive health assessments in patients’ homes and community settings, if needed.

Evaluate, diagnose, and treat acute and chronic medical conditions within the APP scope of practice.

Perform urgent and episodic visits to support Mobile Integrated Health program.

Communicate with paramedics involved with clinical care in MIH program.

Develop and implement individualized treatment plans in collaboration with patients, caregivers, and interdisciplinary team members.

Prescribe medications, therapies, and diagnostic testing in accordance with state regulations and organizational policies.

Provide symptom management, chronic disease management, preventive care, and patient education.

Monitor patients enrolled in the Mobile Integrated Health Program.

Utilize virtual care technologies and telehealth platforms to support ongoing patient monitoring and clinical decision-making.

Identify patients who are admitted to the hospital or in the emergency department that would benefit from MIH and help in enrolling appropriate patients for the same

Collaborate with physicians, nursing staff, social workers, pharmacists, behavioral health providers, paramedics, and care managers to ensure coordinated, holistic care.

Participate in multidisciplinary case reviews and care planning discussions.

Assist with transitions of care following hospitalization, emergency department visits, or skilled nursing facility stays.

Coordinate referrals to specialty care, home health services, community resources, and supportive services.

Address social determinants of health and barriers to care through collaboration with community partners and care coordination teams.

Engage family members and caregivers as integral members of the care team.

Maintain accurate, timely, and complete documentation in the electronic medical record.

Participate in quality improvement initiatives designed to improve patient outcomes, safety, and operational efficiency.

Monitor program quality metrics, patient outcomes, and care management goals.

Participate in clinical case reviews and interdisciplinary rounds.

In conjunction with the Medical Director, assist in the development, implementation, and refinement of Mobile Integrated Health clinical workflows, protocols, and best practices.

Support regulatory compliance and accreditation standards applicable to community-based and home-based healthcare programs.

Participate in safety event reporting and quality…