Nurse Practitioner: Transitional Care

About Cardea Health:

Cardea Health is a non-profit organization dedicated to providing compassionate health care to marginalized populations. Our mission is to create and support programs that protect the health and autonomy of vulnerable individuals and promote equity and social justice to improve the well-being of our entire community. We provide medical support to populations that experience homelessness.

At Cardea, we are dedicated to creating a workplace that celebrates diversity and actively seeks to include underrepresented communities. We believe that diversity drives innovation and fosters a more dynamic, inclusive, and productive work environment. We actively encourage individuals from underrepresented backgrounds to apply for our open positions. We value your unique perspectives, experiences, and talents, and we are committed to providing equitable opportunities for growth and advancement.

Join us in building a team that reflects the rich diversity of our society and let's make a positive impact together.

Primary

Work Location:

Multisite Multisite staff work across several program locations throughout Alameda County, providing care and support wherever it is most needed. These sites offer a range of services, including post-hospitalization medically supported shelter, medical respite care, skilled nursing, and caregiving support.

Job Summary:

Cardea Health is seeking an experienced Nurse Practitioner to provide transitional medical and behavioral health care for individuals residing in interim and permanent housing sites throughout Alameda County. This role supports medically and socially vulnerable populations, including individuals experiencing homelessness who are disconnected from benefits, primary care, and specialty services.

The Nurse Practitioner will evaluate new admissions, identify critical gaps in care, and provide short-term clinical coverage while clients await connection to ongoing primary or specialty providers. Responsibilities include prescribing medications, managing acute and chronic conditions, overseeing wound care, providing medication-assisted treatment for substance use disorders, and collaborating closely with nursing, behavioral health, and substance use navigation teams.

Responsibilities:

Evaluate New Admissions:
Assess new admissions to medically supported interim housing programs, identifying critical gaps in both medical and behavioral health care needs

Prescribe Gap Coverage:
Prescribe medications and treatments for individuals lacking access to essential care while they await connection to primary or specialty providers

Wound Care Management:
Evaluate individuals with chronic or acute wounds lacking specialized care; order and monitor wound care, tracking healing progress and identifying signs of infection

Maintain Critical Care Panel:
Oversee a panel of critically ill patients across various sites. Collaborate with the nursing team to ensure effective clinical monitoring, treatment delivery, and progress assessment

Substance Use Disorder (SUD) Support:
Work closely with the substance use navigation team to identify individuals with substance use disorders. Provide medication-assisted treatment (MAT) as needed

Warm Handoffs to External Providers:
Facilitate smooth transitions for clients by ensuring proper handoff to external primary care providers upon connection

Policy & Procedure Development:
Actively participate in the development and feedback of practice policies and procedures to improve clinical practices

Referral Resource Utilization:
Develop an in-depth knowledge of local and regional referral resources and actively incorporate them into patient care

Data Collection & Research:
Collect and import data for research, quality assurance, and quality improvement initiatives

Adherence to Protocols:
Follow Standard Operating Procedures (SOPs) for clinical practices as a nurse practitioner, adhering to relevant state, county, and healthcare regulations

Harm Reduction & Client Autonomy:
Provide care that respects client autonomy and incorporates harm reduction principles in all clinical interactions

Minimum Required Skills &

Qualifications:

Active Nurse Practitioner…