Primary Care Physician PACE Program
Location: Based at an Adult Day Health Center, with occasional home, hospital, or nursing facility visits
Schedule: Full-time, with rotating night and weekend call coverage
Setting: Program of All-Inclusive Care for the Elderly (PACE)
About the Role
We are seeking a mission-driven Primary Care Physician to provide compassionate, comprehensive, and holistic care for older adults enrolled in a PACE program. This role centers on maintaining participant dignity and independence while delivering high-quality, individualized medical care in collaboration with an Interdisciplinary Team (IDT).
You will serve as the primary medical provider for a designated group of participants primarily at one Day Center with responsibilities that may extend to participant homes, hospitals, or skilled nursing facilities as needed. This position plays a critical role in decision-making and care planning that balances medical needs with realistic quality-of-life considerations.
Key Responsibilities
Clinical Care
Perform comprehensive initial evaluations including history and physicals, goals of care, and end-of-life discussions.
Conduct bi-annual and as-needed reassessments, ensuring care aligns with participants evolving health statuses.
Diagnose and manage acute and chronic conditions in alignment with participants goals and advance directives.
Provide medical oversight of inpatient and specialty care, including hospital admissions and skilled nursing facility stays.
Maintain timely, complete documentation in the medical record in accordance with PACE standards.
Team Collaboration
Partner with Certified Registered Nurse Practitioners (CRNPs), nurses, social workers, therapists, and other IDT members to design and deliver coordinated care plans.
Participate in daily IDT meetings to evaluate participant needs and develop or revise care plans.
Lead or contribute to family conferences, care planning discussions, and team-based quality improvement initiatives.
Actively participate in interdisciplinary discussions about cost-effective, value-based care decisions balancing clinical benefits with holistic participant outcomes.
Continuity of Care
Be available for rotating 24/7 call coverage, shared among the physician team.
Coordinate care transitions across settings (hospital, home, nursing facility) and facilitate timely discharge planning.
Communicate effectively and consistently with participant families regarding medical decisions and care recommendations.
