Physician-Complex Patient Aligned Care Team (PACT)

Job Title

The incumbent will be responsible to provide comprehensive gender specific care, under the Patient Aligned Care Team (PACT) model and intensive case management to a panel of patients with complex chronic medical conditions managed under PCMM guidelines to reduce recurrent ED visits and hospital readmissions.

Duties and responsibilities include, but are not limited to:

• Manages chronic conditions, evaluate and treat inter-current medical conditions. Determine medical assessment and develop treatment plans according to accepted guidelines.
• Collaborates with a Patient Aligned Care Team (PACT) to provide accessible, comprehensive, coordinated, continuous care to an assigned panel of patients.
• The adjusted panel size will allow the COM-PACT team to closely follow their patients through care coordination and intensive case management utilizing a multi-disciplinary team approach to work towards improving patient care outcomes. The team will strive to prevent recurrent emergency department visits as well as frequent readmissions for this population.
• The COM-PACT will carry a team cell phone from 7am-7pm Monday-Friday. The patients are instructed to call this number if their condition deteriorates or prior to any planned trip to an urgent care or ED (VA or Non-VA). The COM-PACT RN will carry the phone during business hours and the phone will be held by the provider 7-8am and 4:30-7pm Monday through Friday.
• Performs a variety of disease prevention related activities including gender and age specific screenings, mental health screenings, and health promotion activities.
• Screens for, evaluates and treats uncomplicated common mental health disorders, including depression and common addictions, with referrals made to mental health providers for further evaluation and treatment as appropriate.
• Physicians are expected to provide clinical oversight and to participate in peer review of other primary care providers through periodic chart reviews.
• Primary care physicians will act as surrogates for absent primary care providers when needed, to include review of CPRS view alerts.
• Primary care physicians will regular attend primary care staff meetings, departmental meetings, and medical staff meetings.
• Timely documentation (notes and encounter forms) is necessary in all areas in accordance with facility policy. All administrative work should be completed in a timely fashion.
• Clinical reminders should be addressed as medically appropriate. Quality of care should meet professional standards.
• Utilization of all Virtual Care modalities is an expectation of this position.
• Provide timely follow-up on results, including completion of view alerts.
• Prescribe medication according to approved formulary, and in accordance with Federal and State Law.
• Consults other specialties as appropriate, according to service agreements.
• Demonstrates flexibility in responding to clinic demands, adhere to personal and professional obligations and responsibilities, practice and maintain ethical standards, and sustain a work environment that is harmonious and customer service oriented.

Work Schedule: Monday through Friday 8am-4:30pm (Note: Work schedules are determined and approved by the supervisor, the incumbent may be required to work various shifts on a permanent or temporary basis based on facility/patient care needs) The candidate must be willing to be placed, detailed or temporarily assigned to other services and/or locations for operational needs or during regional or national emergencies.

Travel/Driving: You may be required to travel for this position.