Job Summary

The Complex Care Advance Practice Provider duties include counseling patients regarding the most appropriate setting to meet their healthcare needs, performing assessments and evaluations of their problems, providing the appropriate information regarding specialist services, and end of life programs. Special attention is given to the PCMH model, evidence-based protocols and screening, and this role functions as a part of a large, integrated care team with the goal of providing whole-person care in the outpatient setting.

Duties and Responsibilities:

• Manage and improve health for patients with multiple chronic medical conditions. Manage a panel of approximately 250 to 300 chronic care ambulatory patients in an office based.
• Work in a team environment (with social work, case management, behavioral health, pharmacy, nutrition, etc.), process feedback, and be open to discussing and implementing plans of care from other members of the team. Work well with a supervising physician.
• Develop strong transitional care plans and track paneled patients along the whole continuum of care including discharges from the hospital, ER, skilled nursing facilities/nursing homes, and home care
• Communicate and interact with alternate levels of care facilities (hospital, ER, skilled nursing facilities) to facilitate appropriate discharge to a lower level of care or back to the AbsoluteCare Medical Center. Familiar with inpatient medicine and the discharge process to help facilitate discharges.
• Treatment of some acute exacerbations of chronic conditions within the AbsoluteCare center, i.e. Lasix for CHF, IVF for Dehydration/Renal Failure, IV antibiotics for various infections, Nebulizer/Solumedrol for COPD/Asthma etc.. Possess a comfort level and the knowledge to differentiate when exacerbation can be treated within AbsoluteCare and when a higher level of care needed. These treatments will involve collaboration and oversight with a supervising physician.
• Accept same day/next day or urgent appointments for patients from home or discharged from the hospital/ER/skilled nursing facility in need of intensified practitioner or case management/social work services to ensure acute episode has resolved and the patient is not admitted/readmitted.
• Track patients and their disease processes to prevent ER visits, admissions to the hospital, and readmissions.
• Understands the PCMH model of care as pertains to specialist care, only utilizes this higher level of care as needed, and not a substitute for primary care using evidence based clinical skills
• Educate patients regarding their chronic diseases, healthy choices, chronic disease progression and advanced directives.
• Practice evidence-based medicine in accordance with the PCMH model of care.
• Track and successfully achieve specified quality metric goals.
• Use technology and the electronic medical record to the highest capability to increase quality initiatives and efficiency within the medical center.
• Participate in multi-disciplinary meetings and recommend treatment alternatives designed to keep patients healthy or resolve on-going clinical issues.
• Perform other duties as required consistent with chronic care and disease management services provided to patients.
• Report to the Medical Director