The Care Transitions Coordinator NP/PA is part of a patient-centered team who delivers culturally sensitive appropriate care to patients in transition between the hospital and primary care setting. The Care Transitions Coordinator works in a collaborative effort across all TVHC departments to remove barriers for accessing healthcare services. The Primary responsibility includes providing outpatient care to patients who have been discharged from the hospital or emergency room setting, and patient education and advocacy. In addition, this position communicates with hospital and health plan based care teams to coordinate patient transitions between levels of care. Under the general direction of the Senior Director of Population Health, and in consultation with the CMO and COO, performs Nurse Practitioner/PA care, including health assessments, thorough history and physical examination, ordering or performing certain diagnostic tests, medication reconciliation and orders, psychosocial evaluations, and any necessary follow up care. The Care Transition Coordinator may oversee clinical care as compatible with their licensure including monitoring of duties performed by LVN and MA staff, and provide administrative oversight to the Care Transitions Patient Navigator and Community Health Worker.
Tiburcio Vasquez Health Center (TVHC) is a leading nonprofit community health center that has provided comprehensive medical, dental, and mental health care since 1971 that primarily serves the community's underserved population. TVHC is located in Hayward, California and is part of the beautiful San Francisco East Bay area.
Maintains access to the established list of high risk patients through health plan portal or other confidential site.