APP) - Geriatrics | Virginia at Home Program

UVA Health

36d

About The Position

The Advanced Practice Provider will deliver comprehensive, patient-centered in-home primary care to geriatric patients with complex medical needs, multimorbidity, and functional/cognitive limitations who are homebound or reside in assisted living/memory care facilities in the greater Charlottesville area and surrounding central Virginia counties (within 40 miles of UVA Medical Center). Key responsibilities include conducting regular house calls, performing thorough assessments, managing chronic conditions, coordinating care, ordering home health services, prescribing medications, and collaborating with an interprofessional team (including physicians, nurses, pharmacists, and caregivers) to promote quality of life, support aging in place, reduce avoidable hospitalizations, and provide holistic, individualized care. Emphasis is on preventive care, caregiver education/support, and advance care planning for older adults. This position is based on a Monday-Friday, daytime (typical business hours) staffing model and does not involve nights, weekends, or holidays. The role is affiliated with the UVA School of Medicine's Section of Geriatric Medicine and supported by UVA's Center for Advanced Practice, which provides dedicated professional development, administrative resources, mentorship, and infrastructure tailored to APPs. This position offers a unique opportunity to practice high-impact geriatric medicine in a community-based, home-visit model within a leading academic health system committed to population health and innovative care for vulnerable older adults. Ideal for experienced or geriatric-focused APPs passionate about house calls and team-based care for the elderly. If applying, along with your CV/resume, please include a cover letter briefly describing your experience and interest in being a part of the program here. This position focuses on individualized, holistic care to promote aging in place, enhance quality of life, support caregivers, prevent avoidable hospitalizations, and coordinate comprehensive services through regular house calls. This role offers a rewarding opportunity to make a meaningful impact on vulnerable older adults in a supportive academic environment committed to innovative, team-based care for geriatrics. Ideal candidates are experienced APPs with a passion for house calls, geriatrics, and patient-centered home-based primary care.

Requirements

Graduate of an accredited graduate school of nursing or physician assistant program with a master’s degree.
Department and unit specific.
License or license eligible as an Advance Practice Provider (Nurse Practitioner, Physician Associate, Certified Registered Nurse Anesthetist, and Certified Nurse Midwife) as set forth by the state of Virginia. If Nurse Practitioner, license to Practice as a Registered Nurse in the Commonwealth of Virginia is required. Must demonstrate and maintain all credentialing and licensing requirements of UVA Health System, the Virginia Board of Medicine or the Virginia Board of Nursing, and appropriate certifying bodies.
Current Basic Life Support (BLS) required.
Current PALS/NRP, as required, specific to position.
Advanced Cardiac Life Support (ACLS) as required, specific to position.

Nice To Haves

Minimum 1–2 years of clinical experience as an APP, preferably in geriatrics, primary care, home-based care, house calls, palliative care, or management of complex multimorbid older adults.
Strong interest or experience in geriatric syndromes (e.g., frailty, dementia, falls, polypharmacy, functional/cognitive decline) and home-visit models of care.
Comfort with independent practice in home settings, including autonomous decision-making, travel within the Charlottesville service area (40-mile radius), and coordination of interdisciplinary services (home health, community resources).
Excellent communication and interpersonal skills for patient/family/caregiver education, advance care planning discussions, and team collaboration.
Demonstrated commitment to patient-centered, holistic care that supports aging in place and reduces avoidable hospitalizations.
Experience with electronic health records (preferably Epic) and familiarity with quality metrics/outcomes tracking in geriatric or home-based programs.
Valid driver's license and reliable transportation for house calls.

Responsibilities

Perform comprehensive in-home primary care assessments, including history, physical exams, cognitive/functional evaluations, and medication reconciliation for older adults with multimorbidity and complex needs.
Diagnose and manage acute and chronic medical conditions, adjust treatment plans, prescribe medications, and order/interpret diagnostic tests/labs as indicated.
Provide preventive care, manage geriatric syndromes (e.g., frailty, falls, dementia, polypharmacy), and address palliative/symptom management needs.
Conduct house calls to patients' homes, assisted living facilities, or memory care settings to deliver personalized, patient-centered care.
Coordinate interdisciplinary services, including ordering home health/skilled nursing, therapy, durable medical equipment, and community resources.
Educate patients, families, and caregivers on disease management, medication adherence, safety, and advance care planning.
Collaborate closely with the interprofessional VaH team (physicians, pharmacists, nurses) to optimize care plans and reduce fragmentation.
Document patient encounters accurately and timely in the electronic health record system per UVA Health and regulatory standards.
Manage scheduling of house call visits, coordinate travel logistics within the service area, and prioritize patient panels for efficient coverage.
Participate in program quality improvement initiatives, data tracking (e.g., utilization metrics, patient outcomes), and reporting to support program goals.
Handle prior authorizations, referrals, and coordination with external providers/agencies as needed.
Adhere to billing/compliance requirements for home-based primary care services.
Maintain active licensure, national certification, and Virginia prescriptive authority as an NP or PA.
Engage in ongoing continuing education focused on geriatrics, home-based care, and house call medicine.
Participate in UVA Center for Advanced Practice offerings, including mentorship, APP-specific professional development, and career advancement opportunities.
Contribute to program education by precepting learners (e.g., APP students, residents) when applicable and sharing geriatric/home-based care expertise.
Stay current with evidence-based practices in geriatric medicine and home-based primary care through literature review and team discussions.
Serve as a key clinical leader within the interprofessional VaH team, guiding care decisions and advocating for patient/family needs in complex cases.
Mentor and support team members, including contributing to onboarding of new staff and sharing best practices in geriatric home-based care.
Participate in program development, expansion efforts, and strategic planning to enhance access and outcomes for homebound older adults.
Lead or contribute to quality improvement projects aimed at reducing hospitalizations, improving caregiver support, or advancing population health goals.
Represent the Virginia at Home program and UVA Geriatric Medicine in community outreach, stakeholder meetings, or collaborations with local agencies.