The Advanced Practice Provider (APP) provides in-home post-discharge management for adults at risk of readmission through Transitional Care Management. Home visits give high-risk patients access to proactive, comprehensive, compassionate, and collaborative care intended to improve health and well-being while helping them remain at home. APPs practice within the applicable scope of practice, privileges, and professional standards. They may practice autonomously and/or in consultation with a collaborating or supervising physician and other health care professionals to assess, diagnose, treat, and manage patients’ health needs. During home visits, the APP evaluates patients, develops individualized plans of care, provides treatment and counseling, and supports health promotion and disease prevention. The role also includes professional education, research, interdisciplinary consultation, and patient advocacy. Prescribing is performed when clinically indicated and in accordance with current APP prescribing guidelines and state and federal law, with medications and authorized refills documented in the patient’s chart. The APP is accountable for care outcomes and maintains national certification, clinical skills, ethical practice, and continuing professional development, including required continuing education. The service area includes Burlington, Camden, and Gloucester counties.
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Career Level
Mid Level