Cleveland Clinic Nurse-Practitioner-Home-Based-Transitional-Care-Program in Independence, Ohio

Job Summary:

The Center for Connected Care has a full time position available for an experienced Nurse Practitioner in Medical Care at Home for a new transitional care program.

Responsibilities to include performing transitional care home visits for high risk Cleveland Clinic patients and communicating findings to the primary care provider. Visits to include medication reconciliation, advanced care planning, addressing transitional care needs, and providing education to patients and caregivers on chronic disease self-management/motivational interviewing. In addition, will work in collaboration with a physician and provide care to home bound patients as part of the Medical Care at Home team. Typical chronic conditions managed include: CHF, COPD, diabetes, HTN and stroke. Completing history & physical examinations and documenting in medical record ? Providing and maintaining a safe environment for the patient ? Educating and counseling patients, families, and/or caregivers as to preventative care, medical problems, psychological problems and spiritual problems to meet the total needs of the patients ? Must be a licensed driver with an automobile that is insured in accordance with state/or organization requirements and is in good working order ? Patience, compassion, and the ability to work successfully with a variety of patients, families and facilities is needed ? Experience is preferred, however new grads with Home Care experience will be considered.

Functions in collaboration with a physician according to a standard care arrangement and specialty certification. Provides advanced nursing care to patients with complex acute, critical, and chronic health conditions, including the delivery of acute care services. Practice with a variety of specialty-based populations including neonatal, pediatric, and adult. Practices in any setting in which patients require complex monitoring and therapies, high intensity nursing intervention, or continuous nursing vigilance within the range of high-acuity care.


  • Assesses health status by obtaining relevant health and medical history.

  • Performs a physical exam based upon the age and patient history as per the Standard Care Arrangement with a collaborating physician.

  • Identifies significant health and medical risk factors.

  • Documents findings in medical record.

  • Orders, interprets and evaluates laboratory tests and other diagnostic studies to assess patient's clinical problems and health care needs.

  • Develops a diagnosis by analyzing and synthesizing collected data.

  • Develops a treatment plan in collaboration with the physician and members of multidisciplinary care team.

  • Performs diagnostic or therapeutic interventions consistent with certification, law and Cleveland Clinic privileges.

  • Prescribes and monitors medications as allowed by prescriptive authority through the applicable state Board of Nursing and CCF policy. Develops patient education plan.

  • Participates in medical team rounds.

  • Collaborates with nursing, medical and other healthcare team members regularly to ensure safe, quality patient care.

  • Performs admission history and physical; documents progress notes; prepares discharge summaries as required.

  • Assists with and facilitates discharge planning.

  • Other duties as assigned.


  • Effective 05/01/2014: MSN required upon hire or within 5 years of hire for external hires and internal hires moving from a non-APN licensed role to an APN licensed role.


  • Licensed as Registered Nurse (RN) in applicable state, national certification as nurse practitioner (APN) by nationally accredited organization, current certificate of authority by applicable state Board of Nursing, certificate to prescribe (CTP) preferred.

  • Basic Life Support (BLS) Healthcare Provider required; Advanced Cardiac Life Support (ACLS) or Pediatric Advanced Life Support (PALS) may be required based upon work setting.

Complexity of Work:

  • Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.

  • Must be able to work in a stressful environment and take appropriate action.

Work Experience:

  • Two years of clinical nursing experience preferred.

Physical Requirements:

  • Typical physical demands include the ability to walk and stand for long periods of time.

  • Manual and finger dexterity and eye/hand coordination to perform physical examinations.

  • Requires corrected vision and hearing to a normal range.

  • Occasionally lifts and carries items weighing up to 50 pounds.

  • May require exposure to communicable diseases and/or body fluids.

Personal Protective Equipment:

  • Follows standard precautions using personal protective equipment as required.

The policy of Cleveland Clinic and its system hospitals (Cleveland Clinic) is to provide equal opportunity to all of our employees and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. Job offers will be rescinded for candidates for employment who test positive for nicotine. Candidates for employment who are impacted by Cleveland Clinic’s Smoking Policy will be permitted to reapply for open positions after 90 days. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic facility.

Cleveland Clinic is pleased to be an equal employment employer: Women/Minorities/Veterans/Individuals with Disabilities