The mission of the Transitional Care Coordination Program is to ensure intensive, coordinated, outpatient care for patients with complex chronic health problems that leave them medically vulnerable. Our vision is to address our patients’ needs holistically; to improve health and well-being through coordinated medical services with emphasis on the social determinants that affect health such as housing, food and transportation.
We do this by providing coordination and support for complex, vulnerable patients whose chronic health conditions and psychosocial challenges place them at high risk for repeated hospital admission or frequent returns to the emergency room. We provide comprehensive post hospital care coordination via telephone outreach, community visits and in-home visits as needed to ensure patient is supported in their health care needs/goals after they return to the community.
Company DescriptionThe University of Maryland Medical System (UMMS) is an academic private health system, focused on delivering compassionate, high quality care and putting discovery and innovation into practice at the bedside. Partnering with the University of Maryland School of Medicine, University of Maryland School of Nursing and University of Maryland, Baltimore who educate the state’s future health care professionals, UMMS is an integrated network of care, delivering 25 percent of all hospital care in urban, suburban and rural communities across the state of Maryland. UMMS puts academic medicine within reach through primary and specialty care delivered at 11 hospitals, including the flagship University of Maryland Medical Center, the System’s anchor institution in downtown Baltimore, as well as through a network of University of Maryland Urgent Care centers and more than 150 other locations in 13 counties. For more information, visit www.umms.org.
QualificationsMaster of Science Degree with completion of an appropriate primary or acute care Nurse Practitioner program. Registered and currently recorded with the Maryland Board of Examiners of Nurses and Certified as a Nurse Practitioner in the State of Maryland. Certified in area of specialty. DEA and CDS eligibleBCLS as requiredAdditional Information.