A Maryland, PCMH model clinic 30 minutes northeast of D.C. is looking for a Primary Care Physician (Family Medicine or Internal Medicine) with experience treating patients with multiple chronic diseases. Must believe in the value of a team-oriented Patient Centered Medical Home (PCMH) model. The Primary Care Physician participates as a part of a comprehensive multi-disciplinary team providing wrap around care to patients in a program designed to educate, empower, and improve the health of patients. This physician is also 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 Primary Care Physician provides physician services including counseling patients regarding the most appropriate setting to meet their healthcare needs, performing diagnostic evaluations and treatment, 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 that includes; nurse practitioner, medical assistant, nurse care manager, clinical social worker, and office coordinator. Responsibilities:- Focuses on the management and improvement of health for patients with multiple chronic medical conditions.- Able to work in a team environment, process feedback, and facilitate discussion and implementing plans of care from other members of the team.- Average patients per day: 13 - 15 - 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.- Develop care plans in conjunction with multidisciplinary team members specific to each patient.- Treatment of some acute exacerbations of chronic conditions onsite, utilizing the ambulatory care infusion 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 at the clinic and when a higher level of care needed.- Accepts 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.- 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 a well-trained primary care physician with evidence based clinical skills.- Assists with educating patients regarding their chronic diseases and healthy choices.- Assists with the education and discussion of chronic disease progression and the need for advanced directives.- Practices evidenced based medicine and in accordance with the PCMH model of care.- Able to keep track of and successfully obtain specified quality metric goals.- Uses technology and the electronic medical record to the highest capability to increase quality initiatives and efficiency within the medical center.- Participates in multi-disciplinary meetings and recommends treatment alternatives designed to keep patients healthy or resolve clinical issues.- Perform other duties as required consistent with chronic care and disease management services provided to patients.Qualifications:- Licensed physician in the state of Maryland- Board certified Internal Medicine or Family Practice is required- BLS certification required- Strong focus on customer service is required- Experience in population health management is preferred- Experience in working with psychosocially and medically complex patients is strongly preferred- Knowledge or experience with NCQA PCMH model is preferred- Must be able to work as part of a multidisciplinary team with constant collaboration within and across provider teams- Innovative and creative and innovative self-starter to help solve patient's problems- Experience and comfort around maximizing EMR systems- Problem-solving and the ability to be creative in those solutions- Strong oral and written communication skills
