Advanced Practice Provider-Mobile Integrated Health Program
Lifespan
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Job summary
Brown University Health’s Mobile Integrated Health (MIH) Advanced Practice Provider delivers comprehensive assessment, care planning, and management in patients’ homes and community settings, collaborating with physicians, nurses, social workers, paramedics, and partners. The role emphasizes hospital avoidance, transitions, and evidence-based practice leveraging telehealth for ongoing monitoring.
The APP works within a value-driven environment, supporting compassionate, accountable, respectful,
Qualifications
- Clinical assessments in home/community settings.
- Treat acute and chronic conditions within APP scope.
- Collaborate with interdisciplinary care teams.
Responsibilities
- Conduct home health assessments and care planning.
- Develop and implement treatment plans with patients and families.
- Provide telehealth and in-person care, monitor outcomes.
- Coordinate transitions of care and referrals to services.
- Maintain EMR documentation and participate in quality initiatives.
Skills
Education
Job description
The Mobile Integrated Health (MIH) Advanced Practice Provider (APP) serves as a key clinical provider within an innovative, community-based care delivery model designed to improve coordination and outcomes for medically complex patients. The APP provides comprehensive assessment, treatment, care coordination, and transitional care services in patients' homes, residential settings, and other community locations, while collaborating closely with physicians, nurses, care managers, social workers, paramedics, and community partners.
The APP delivers high-quality, patient-centered care that supports hospital avoidance, reduces unnecessary emergency department utilization and readmissions, and promotes patients' ability to safely remain in their homes and communities. The APP utilizes evidence-based practice, advanced clinical decision-making, telehealth technology, and interdisciplinary collaboration to manage acute, chronic, and transitional care needs.
Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.
Conduct comprehensive health assessments in patients' homes and community settings, if needed.
Evaluate, diagnose, and treat acute and chronic medical conditions within the APP scope of practice.
Perform urgent and episodic visits to support Mobile Integrated Health program.
Communicate with paramedics involved with clinical care in MIH program.
Develop and implement individualized treatment plans in collaboration with patients, caregivers, and interdisciplinary team members.
Prescribe medications, therapies, and diagnostic testing in accordance with state regulations and organizational policies.
Provide symptom management, chronic disease management, preventive care, and patient education.
Monitor patients enrolled in the Mobile Integrated Health Program.
Utilize virtual care technologies and telehealth platforms to support ongoing patient monitoring and clinical decision-making.
Identify patients who are admitted to the hospital or in the emergency department that would benefit from MIH and help in enrolling appropriate patients for the same
Collaborate with physicians, nursing staff, social workers, pharmacists, behavioral health providers, paramedics, and care managers to ensure coordinated, holistic care.
Participate in multidisciplinary case reviews and care planning discussions.
Assist with transitions of care following hospitalization, emergency department visits, or skilled nursing facility stays.
Coordinate referrals to specialty care, home health services, community resources, and supportive services.
Address social determinants of health and barriers to care through collaboration with community partners and care coordination teams.
Engage family members and caregivers as integral members of the care team.
Maintain accurate, timely, and complete documentation in the electronic medical record.
Participate in quality improvement initiatives designed to improve patient outcomes, safety, and operational efficiency.
Monitor program quality metrics, patient outcomes, and care management goals.
Participate in clinical case reviews and interdisciplinary rounds.
In conjunction with the Medical Director, assist in the development, implementation, and refinement of Mobile Integrated Health clinical workflows, protocols, and best practices.
Support regulatory compliance and accreditation standards applicable to community-based and home-based healthcare programs.
Participate in safety event reporting and quality investigations as required.
Serve as a clinical resource and mentor for team members.
Promote a culture of collaboration, innovation, accountability, and patient-centered care.
Participate in provider meetings, education programs, committee work, and organizational initiatives.
Support program growth and innovation through active engagement in process improvement and strategic initiatives.
Represent the Mobile Integrated Health Program in interactions with healthcare partners, community agencies, and stakeholders as appropriate.
Performs other duties as assigned.
Current registration as a Physician Assistant or Nurse Practitioner in the State of Rhode Island.
Master's or Doctoral degree in Nursing from an accredited program.
Current Nurse Practitioner certification in Family Practice (FNP), Adult-Gerontology (AGNP), Adult-Gerontology Acute Care (AGACNP), or other relevant specialty.
Graduate of an accredited Physician Assistant program.
Current NCCPA certification.
Current unrestricted state licensure as a Nurse Practitioner or Physician Assistant.
Current DEA registration and prescriptive authority as applicable.
Current Basic Life Support (BLS) certification.
Advanced Cardiac Life Support (ACLS) certification preferred.
Valid driver's license and reliable transportation.
Minimum of three (3) years of clinical experience as an Advanced Practice Provider required.
Experience in Hospital Medicine, Emergency Medicine, Internal Medicine, Family Medicine, Geriatrics, Critical Care, Palliative Care, Home-Based Primary Care, or Transitional Care preferred.
Experience providing care in home-based, community-based, mobile, virtual, or non-traditional care settings preferred.
Experience caring for medically complex, high-risk, or vulnerable patient populations strongly preferred.
Prior experience working within interdisciplinary care teams required.
Commitment to delivering evidence-based, high-quality care to diverse patient populations.
Strong clinical assessment, diagnostic reasoning, and medical decision-making skills.
Ability to work independently in home and community environments while maintaining close collaboration with the care team.
Excellent verbal, written, and interpersonal communication skills.
Demonstrated ability to establish trusting relationships with patients, families, and caregivers.
Strong organizational and time management skills.
Ability to prioritize and manage multiple complex patient needs.
Skilled in identifying clinical deterioration and initiating appropriate escalation pathways.
Knowledge of population health, care transitions, chronic disease management, and social determinants of health.
Proficiency with electronic medical records, mobile technology platforms, and telehealth applications.
Knowledge of patient safety principles and quality improvement methodologies.
Ability to function effectively in a rapidly evolving healthcare environment.
Demonstrated commitment to professionalism, teamwork, and patient advocacy.
None.
Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.
Newport Hospital - 11 Friendship Street Newport, Rhode Island 02840
M-F 8am -5pm
Day
8 hours
Yes
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