JOB SUMMARY
Under the supervision of the Associate Director of Post Acute and Care at Home Programs (MD/DO), the Lead
Advanced Practice Provider (APP) - Transitions of Care (TOC) is responsible for direct patient care for low-income
and uninsured patients in post-acute environments as appropriate, including Skilled Nursing Facilities (SNFs), and
the Care at Home program (home visits).

The Lead APP-TOC will work in conjunction with Nurse Case Managers, Social Workers, Community Health Workers,
Pharmacists, Physicians and other care team members to provide transitions of care/navigation services, working
in collaboration with inpatient care teams and other Central Health medical and case management teams. As with
other providers in the department, the Lead APP-TOC will coordinate with primary care providers, and other
providers in the hospital, post-acute, outpatient, and community settings.

The Lead APP-TOC will also have the opportunity for programmatic development within the Department of
Transitions of Care. As the Lead APP, this position will supervise and manage other APPs in the Transitions of Care
Department, and provide clinical direction, education, and support. They will collaborate with the TOC Director,
Associate Director, and Lead Physicians, TOC Director of Nursing and Associate Director of Nursing, and Nurse
Managers, as well as TOC Operations leadership. The Lead APP-TOC will advocate and liaison for all TOC APPs.
Administrative time will be inclusive of leadership meetings (distributed across the week based on meeting times)
and other administrative duties. This will include protected decrease in patient census/admissions and dedicated
protected time during the week for additional duties as assigned by team (10%).

Central Health's mission is to care for those within the county who need healthcare services and to improve the
health of our community. Mission alignment and empathetic approach are central to our goal of advancing health
equity and inclusion. This position models a commitment to the organization's mission, vision, and values to
support an unparalleled patient experience and positive clinical outcomes.

Essential Functions

-Provide direct patient care to patients in Skilled Nursing Facilities (SNFs) and the Transitional Care at Home program.
-Collaborate with the case management teams across the Central Health Enterprise to coordinate patient care.
-Collaborate with attending physicians to provide care at SNFs.
-Participate and lead quality and care review meetings for patients in the post-acute program.
-Facilitate collaboration with partner organizations to ensure the provision of compassionate, and effective care coordination for hospitalized patients and medical care to other patients in post-acute settings who require medical service.
-Work in close consultation with the patient’s primary care provider and other licensed health care facility providers to deliver medical care of MAP patients while admitted in post-acute environments in the best interest of the patient and consistent with Central Health’s policies, mission and goals.
-Communicate effective information to patients, families, colleagues, nursing and other health care professionals, as appropriate.
-Prepare and provide necessary timely and accurate reports and forms, as may be required by Central Health or facility in the performance of medical services.
-Coordinate care with skilled nursing facility team members and other Physicians and Advanced Practice Providers to eligible patients in skilled nursing facilities.
-Plan and coordinate care daily with all members of Central Health’s care team to assure maximum quality and efficiency of care between Eligible Patients, Physicians, Advanced Practice Providers, case management and nursing.
-Perform medical and administrative services under general guidance and minimal supervision with accountability for specific organizational-level goals.
-Work closely with families of diverse patient populations.
-Facilitate effective communication with Case Management/Care Coordination teams regarding readmission prevention.
-Proactive collaboration to facilitate discharge teaching for readmitted/high risk patients prior to or at discharge.
-Develop and execute the planning, implementation and evaluation of service delivery, patient experience, and care.

Additional responsibilities of the Lead APP-TOC include:
-Manage workforce planning and utilization to include recruitment, onboarding, separation, and professional growth and development of all APPs-TOC.
-Develop vision, strategy, and performance goals for APPs-TOC. Performance evaluations to include development of competency plans, goals, and making recommendations for improvement and success.
-Provide on-going program evaluation and recommendations to the Director of Transitions of Care and the Associate Director of Post-Acute Care and Care at Home for continuous growth and quality improvement.
-As a Wellness and Sustainability champion, advocate and provide opportunities for staff to maintain healthy effective ways to promote work-life integration.
-Manage and support the implementation of new initiatives and ensure strategy and initiatives are coordinated.

-Participate in quality strategies to evaluate compliance with evidence-based guidelines, standards and to identify opportunities to improve patient outcomes.
-Foster a welcoming environment for learners in the clinical space.
-Adhere to all local, state, and federal regulations. Collaborate with enterprise-wide APP leadership

Performs other duties as assigned.

MINIMUM EDUCATION:
Graduation from an accredited School of Physician Assistants OR Master’s degree from an accredited School of Nursing.

MINIMUM EXPERIENCE (REQUIRED):

2 years experience as an advanced practice provider in a transitions of care environment

PREFERRED EXPERIENCE:

Experience with Epic and training or support for Epic end user programs

Knowledge of medical care and management of patients in SNF and other transitions of care facilities

Demonstrated knowledge of Joint Commission standards, HIPAA regulations, Quadruple Aim, and Value Based Care

REQUIRED CERTIFICATIONS/LICENSURE:
• Unrestricted license to practice as a Physician Assistant in the State of Texas OR unrestricted license to practice Nursing in the State of Texas/current credentialing as an Advanced Nurse Practitioner by the Texas Board of Nurse Examiners.
• Current Drug Enforcement Agency (DEA) for the purpose of writing prescriptions.
• Current Healthcare Provider Cardiopulmonary Resuscitation (CPR) through American Heart Association.
• Current Basic Life Support Certification for Healthcare Providers through American Heart Association.