Advanced Practice Clinician Pb Care Coordination

Become part of the Beebe team - an inclusive team positioned in a vibrant coastal community. Enjoy a fulfilling career as you support the health of our patients and a team focused on excellence.

The Post-Acute Care / Transitions of Care Nurse Practitioner is an advanced practice provider responsible for managing medically complex and high-risk patients as they transition from the acute care setting into the community and post-acute continuum. The NP provides proactive clinical management with an emphasis on chronic disease stabilization medication management early recognition and treatment of clinical deterioration reduction of preventable hospital readmissions and avoidable emergency department utilization and successful connection to longitudinal care.

Working collaboratively with physicians primary care providers specialists care managers pharmacists home health post-acute providers and community resources the NP serves as a clinical bridge between the hospital and the patients next level of care.

• Evaluate high-risk patients following hospitalization observation stays emergency department encounters or post-acute facility discharge.
• Review the hospitalization course discharge plan diagnostic results pending tests medication changes and follow-up requirements.
• Perform timely post-discharge clinical assessments based on patient acuity and identified risk in post acute facilities.
• Identify gaps in the discharge plan and intervene before they result in clinical deterioration.
• Establish an individualized transition-of-care plan with the patient caregiver and interdisciplinary care team.
• Facilitate timely transition back to the patients primary care provider and specialists once stabilized.
• When applicable support Transitional Care Management requirements including timely patient/caregiver communication medication reconciliation follow-up and coordination of services.

Provide evidence-based management of patients with complex or multiple chronic conditions including congestive heart failure COPD and other chronic pulmonary disease diabetes mellitus chronic kidney disease hypertension cardiovascular disease frailty and other diagnoses associated with frequent ED utilization or hospitalization.

• Assess disease stability and progression.
• Adjust medications within scope of practice and applicable collaborative requirements.
• Monitor relevant laboratory and diagnostic findings.
• Reinforce disease-specific self-management and individualized action plans.
• Recognize early warning signs and intervene before symptoms progress to a higher level of care.
• Coordinate escalation to primary care specialty care urgent evaluation or emergency services when clinically indicated.

• Identify patients at elevated risk for readmission or ED utilization.
• Proactively monitor patients during vulnerable care transitions.
• Provide rapid clinical assessment when a patients condition changes.
• Develop alternatives to ED utilization when safe and clinically appropriate.
• Address common drivers of preventable utilization including medication discrepancies inability to obtain medications delayed follow-up chronic disease exacerbation social barriers caregiver limitations and lack of timely clinical access.
• Review ED visits and readmissions to identify opportunities for earlier intervention and improvement in the transition plan.

• Complete comprehensive medication reconciliation following transitions of care.
• Identify duplications omissions contraindications interactions and barriers to medication adherence.
• Reconcile discharge medications with pre-hospital and outpatient medication regimens.
• Collaborate with physicians pharmacists specialists patients and caregivers to resolve medication discrepancies.
• Educate patients and caregivers regarding medication purpose administration monitoring and appropriate escalation for adverse effects.

• Serve as a clinical liaison between acute care and community/post-acute providers.
• Collaborate with primary care hospitalists specialists care management home health SNF/post-acute providers assisted and independent living communities pharmacy rehabilitation services palliative care and community organizations.
• Ensure clinical information and treatment-plan changes are communicated to appropriate members of the care team.
• Support reliable handoffs closed-loop communication and reduced fragmentation across the continuum.

• Educate patients and caregivers regarding diagnoses medications symptoms and treatment plans.
• Establish clear instructions defining what to do and who to call when symptoms change.
• Assess patient and caregiver understanding using appropriate education techniques.
• Promote patient self-management and engagement.
• Identify caregiver burden and connect families to appropriate support resources.
• Incorporate goals of care and patient preferences into care planning and escalate advance-care-planning needs to appropriate providers.

Assess barriers that may contribute to poor outcomes including medication affordability food insecurity transportation housing instability health literacy limited caregiver support difficulty accessing primary or specialty care and behavioral health needs. Collaborate with care management social work pharmacy and community partners to address identified barriers.

• Critical thinker with the ability to proactively identify and mitigate risk
• Collaborative work style
• Strong communication and interpersonal skills with both internal and external stakeholders
• Proficiency in EMR systems
• Proficiency in Microsoft Office Suite (Excel PowerPoint Word Visio etc.)

• Masters or doctoral degree from an accredited Nurse Practitioner program.
• Current state RN and APRN/NP licensure.
• National board certification appropriate to the population served such as Adult-Gerontology Primary Care NP or Family NP.
• Prescriptive authority and DEA registration when required for the scope of the position.
• Current BLS certification.
• Strong clinical assessment diagnostic and chronic disease management skills.
• Ability to practice with significant autonomy while maintaining effective physician and interdisciplinary collaboration.