Serving patients aged 18 and above, primarily from Multnomah, Clackamas, and Washington counties with limited out-of-area exceptions.
Services Provided:
- In addition to adult Primary Care, our specialty & consult services include:
- Addiction Services (including Medication-Assisted Treatment) and Complex Pain Management
- Behavioral Health, Mental Health, and Wellness
- Bone Health
- Chronic Disease Management and Diabetes Care
- Geriatrics and Senior Care
- Gender-Affirming and LGBTQ+ Primary Care
- Hepatitis C Treatment
- HIV/AIDS Care and PrEP (HIV Pre-Exposure Prophylaxis)
- Long Covid
- Procedure Clinic (including Joint Injections)
- Women’s Health Care
Department Key Responsibilities:
Supports complex, high-risk patients in the outpatient setting through advanced care coordination a
- Leading multimodal triage and proactive care coordination, utilizing telephone, electronic messaging, and in-person communication to facilitate timely clinical interventions and reduce avoidable acute care utilization.
- Embedding clinical nursing expertise within ambulatory workflows, supporting real-time decision-making and seamless care transitions across settings.
- Serving as a central point of contact for patients, families, and interdisciplinary team members to promote continuity of care and address emerging clinical concerns in a timely, efficient manner.
- Designing, implementing, and refining ambulatory care models that support safe, scalable, and sustainable nursing practice in alignment with clinic operations and patient population needs.
- Driving improvements in patient outcomes by integrating nursing judgment with patient education, system navigation, and advocacy in a complex outpatient care environment.