Medical Home Team Transitional Care NP in The Woodlands, Texas

Medical Home Team

Medical Home Team Practitioner

Position Title: Acute Care Transitional Nurse Practitioner

Reports To: Chief Clinical Officer / Collaborating Physician


The Acute Care Transitional Nurse Practitioner (ACT-NP) practice is derived from the management of high-acuity patient care along the wellness-to-illness continuum. The ACT-NP assesses patients in their residence with acute, critical, and/or complex chronic illnesses through their health history, physical and mental status examinations, and health risk appraisals. Diagnostic reasoning, advanced therapeutic interventions, and referral to and consultation with other members of the inter-professional health care team are intrinsic to this role utilizing Evidence Based Practice.

The ACT-NP acknowledges and incorporates the dynamic nature of acute, critical, and/or complex chronic illnesses in the provision of care. The ACT-NP also individualizes care with respect to gender, age, developmental level, race, cultural differences, individuality, ethnicity, spiritual beliefs, lifestyle, sexual orientation, socioeconomic status, disability, and family configuration.

The focus of the ACT-NP is the provision of restorative, curative, rehabilitative, palliative, and/or supportive care as determined by patient needs for a specific time-frame as deemed by the Transitional Care Model (60-days); preventing readmissions or visits to the Emergency Room (ER); transitioning care afterwards back to their Primary Care Provider and/or a Chronic Care Team.

This position is in the Field working with the patients inside their residence. This a full-time salaried position.


  • Taking comprehensive histories and providing physical examinations and other health assessment and screening activities

  • Diagnosing, treating, and managing patients with acute and chronic illnesses and disease

  • Ordering, performing, supervising, and interpreting laboratory and imaging studies

  • Prescribing medications, durable medical equipment, and advanced therapeutic interventions

  • Developing specialized psychomotor skills in the performance of procedures

  • Initiating health promotion, disease prevention, health education, and counseling

  • Collaborating and communicating with members of the inter/intra professional health care team

  • Assessing, educating, and providing referrals for the patient, family, and caregiver

  • Implementing transitions in the levels of care

The ideal candidate for this position will possess competencies or previous experience in the following areas:

  • Home Visits

  • Geriatric Medicine

  • Critical Care

  • Emergency Medicine

  • Acute Care


Nearly 100% of the position is travel spent going to patient’s home, assisted living and independent living, senior apartments and periodic office meetings.

ID: 2016-1660