Home Visit APRN / PA - Naples

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. Locations : Naples (FT and or PT) 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.

Job Status / Benefits :

Education, Training, Experience :

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