Overview
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 patient's next level of care.
Responsibilities
1. Post-Acute and Transitional Care Management
- 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 patient's 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.
2. Chronic Disease Management
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.
3. Readmission and Emergency Department Avoidance
- Identify patients at elevated risk for readmission or ED utilization.
- Proactively monitor patients during vulnerable care transitions.
- Provide rapid clinical assessment when a patient's 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.
4. Medication Reconciliation and Management
- 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.
5. Care Coordination and Continuum Integration
- 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.
6. Patient and Caregiver Engagement
- 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.
7. Social Drivers of Health
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.
Competencies Skills
- 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.)
Credentials
Education
Required
- Master's 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.
EntryUSD $126,672.00/Yr.
MaxUSD $173,101.00/Yr.
