The most medically vulnerable patients’ needs are hard to address in today’s fee-for-service system. Care is fragmented and in time-limited slots.
Complex and frail patients living with multiple co-morbidities benefit from additional care that comes to them. Care that is coordinated with their existing doctors and specialists.
Our physician-led teams specialize in house calls to bring medical care to patients where they reside and when they need it. Our multidisciplinary model includes physicians, nurse practitioners, physician assistants, social workers, dietitians, behavioral health specialists, social workers, nurse care managers and care coordinators.
See the whole picture and treat the whole patient by bringing advanced medical care to patients in their homes.
As a Physician, your duties will be to:
- Function as day-to-day clinical leader, providing decision support to nurse practitioners and directing the multidisciplinary team
- Perform 4-6 preventive visits daily to optimize chronic conditions, assess home environment, educate patients and caregivers, and develop proactive care plans
- Perform urgent care visits in the home to avoid unnecessary ED transfers and hospital admissions
- Leverage the support of nurse care manager, behavioral health, social work, pharmacy, and dietician to meet patients’ medical, biopsychosocial, and financial needs
- In situations where there is no existing PCP for the patient, assume responsibility as PCP to drive care and continuity for patients
- In situations where there is an existing PCP for the patient, help to co-manage the patient with the PCP and serve as an extension of clinical care into the home
- Coordinate with other physicians across the continuum of care, including PCP, hospitalist, and SNF providers to smooth transitions and prevent readmissions
- Coordinate and offer medical direction to community-based organizations touching the lives of our patients, including housing and caregiver agencies, health plan contracted social work services, home health, adult day health centers, and behavioral health
- Board Certified / Board Eligible Physician, preferably Internal Medicine, Family Medicine, or Emergency Medicine
- Doctor of Medicine M.D. or Doctor of Ostepathy D.O. from an accredited educational institution
- DEA registration
- Experience managing complex, polychronic patients and comfort with high acuity
- Dedication to transforming care for the sickest and frailest in a marginalized population
- Eagerness to work with a diverse and multidisciplinary team
- Must be board certified at the time of hire or able to obtain board certification during the eligible timeframe (5 years following completion of residency or other training)