Specific Duties and Responsibilities

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) 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.
• Treat 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.
• 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 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.