Job Summary:

As a “Home Visit APRN or PA” you will function as a day-to-day clinical leader, providing support and care during patient transitions from acute to home: directing the multidisciplinary team.

Primary Functions:

• Perform 6-8 preventive visits daily to optimize chronic conditions, assess home environment, educate patients and caregivers, and develop proactive care plans.
• Perform timely new care visits and follow up care as needed in the home, while our focus is to avoid unnecessary ED transfers and hospital admissions.
• In situations where there is no existing PCP for the patient, assume responsibility as interim provider and drive care and continuity for patients.
• In situations where there is an existing PCP for the patient, help to co-manage the patient with the PCP and serve as an extension of clinical care into the home.
• Coordinate with other physicians across the continuum of care, including PCP, hospitalist, and SNF providers to smooth transitions and prevent readmissions.
• Coordinate and offer medical direction to community-based organizations touching the lives of our patients, including housing and caregiver agencies, health plan contracted social work services, home health, adult day health centers, and behavioral health.

Education, Training, Experience:

• Active FL medical license in good standing