This is not your typical healthcare company. This is not your typical medical center. This is not your typical primary care role.
PCMH model clinic in Baltimore is seeking a dynamic, mission-driven primary care provider to put the principles of team-based care and population health into action for our medically complex & socially vulnerable members. Unfettered from the traditional fee-for-service model, through unique provider-payor relationships, this healthcare orgnization is designed to care for society’s sickest patients. Prior to coming to this clinc, their patients are typically ill-served by the uncoordinated traditional health care system, bouncing between emergency rooms, hospitals, and specialists several times a year. The role of their PCPs is break the status quo and transform our members health & lives. In order to do so, Their PCPs lead an integrated care team of nurse care managers, social worker, behavioral health specialist, and community outreach workers to deliver complex primary care that addresses the patients’ health and life issues. They offer complex, coordinated medical care through our medical teams with our onsite infusion center, full pharmacy, and lab & imaging suites. They also treat the social determinants of health, addressing housing instability, food insecurity, or simply loneliness through our integrated care team.
Reporting directly to the Medical Director, the internal/family medicine trained primary care provider utilizes their experience treating patients with multiple chronic diseases to deliver concierge-level care to our community’s most medically complex and socially vulnerable individuals. The PCP is responsible for helping develop transitional care plans for patients being discharged from hospitals, ERs, skilled nursing facilities, and any other venue that requires transitional care. This in turn lowers unnecessary ER utilization, inpatient utilization, specialty utilization, and re-admissions while increasing the quality of care delivered. The PCP provides services including 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 working as a collaborative team including physicians, case managers, social workers, psychologists, pharmacists, and nutritionists to educate and empower our patients to make healthier choices.
Specific Duties and Responsibilities
Complex Clinical Care:
Direct Complex Clinical Care:
• Focuses on the management and improvement of health for patients with multiple complex and chronic medical conditions.
• Able to work with and lead a team (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.
• Develop strong transitional care plans and able to help keep track of 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) in order to facilitate appropriate discharge to a lower level of care or back to the Medical Center. Familiar with inpatient medicine and the discharge process in order to help facilitate discharges.
• Treat acute exacerbations of chronic conditions within the clinic, 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 their clinic and when a higher level of care needed.
• 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 physician or case management/social work services to ensure acute episode has resolved and the patient is not admitted/readmitted.
• Vigilant in keeping track of patients and their disease processes in order to prevent ER visits, admissions to the hospital, and readmissions.
• Understand the PCMH model of care as pertains to specialist care, only utilizing this higher level of care as needed, and not a substitute for a well-trained primary care physician with evidence based clinical skills.
• Educate members on chronic disease progression and the need for advanced directives where applicable.
• Practices evidenced based medicine and in accordance with the PCMH model of care.
Candidate Qualifications
• Licensed provider (Physician Assistant or Nurse Pracitioner) in the state of Maryland
• Trained in Internal Medicine or Family Practice
• BLS certification required
• Mission-Driven to serve the underserved
• Strong focus on customer service is required
• Work without ego, and thoughtfully build successful relationships with team members and our partners
• Experience in population health management is preferred
• Experience in working with psycho-socially and medically complex patients is strongly preferred
• Must be able to work as part of a multidisciplinary team with constant collaboration within and across provider teams
• Experience and comfort utilizing EMR
• Problem-solving and the ability to be creative in those solutions
• Strong oral and written communication skills

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