Primary Care Physician - Compass PLUS Program

Compass PLUS is a home and community-based care management program for the patients with the highest complexity and hospital utilization in the Mass General Brigham MassHealth Accountable Care Organization (ACO). All participants receive clinical and support from a multi-disciplinary care team.
The Compass PLUS Primary Care Physician (PCP) is responsible for the care of a small panel of highly complex patients in the Compass PLUS program. Patients who see the Compass PLUS PCP typically have difficulty engaging in office-based primary care or are hospitalized too frequently to attend outpatient visits.

Mass General Brigham Community Physicians Organization | Greater Boston, MA

About Compass PLUS

Compass PLUS is designed for clinicians who thrive in high-need, outpatient environments. This innovative program supports patients facing complex medical and social challenges, using a hands-on and highly collaborative care approach that prioritizes individual patient needs.

Care is delivered outside traditional offices, with teams-including a Nurse Practitioner, Nurse, Behavioral Health Clinician, and Community Health Worker-working directly in patients' homes or community spaces. Most patients stay connected to their existing PCP, but for those with the greatest needs, the Compass PLUS physician takes over care, aiming to eventually transition them back to standard primary care.

For patients requiring the most intensive support, the Compass PLUS physician becomes their primary provider, focusing on meeting their holistic needs and reintegrating them into traditional outpatient care when feasible.

About the Role

This role is ideal for primary care physicians seeking to spend more time with fewer patients-managing a small panel of approximately 100 medically and socially complex individuals. You'll serve as the PCP for those fully transitioned into the Compass PLUS program and consult with other providers caring for high-risk patients. The majority of your work will be conducted in homes and community settings, allowing you to address barriers directly and build strong relationships with patients.

Key Responsibilities

• Deliver comprehensive outpatient primary care to a small group of high-acuity patients, focusing on relationship-based, intensive care
• Work closely with multidisciplinary care teams in community and home settings
• Create and execute personalized care plans that address medical, behavioral, and social needs
• Consult with PCPs and teams across the system, sharing expertise in managing complex patients
• Support transitions between inpatient, emergency, and outpatient care, always with a patient-centered approach
• Collaborate with patients and teams to improve health outcomes and decrease unnecessary hospital use

Practice Details

• Panel size of about 100 patients enables more dedicated, intensive care
• Care is primarily delivered in homes and community locations with traditional office space available as needed
• Work is centered in the Greater Boston area
• Local travel is necessary, with occasional regional trips (1-2 times per month)
• No evening or weekend call obligations
• Enjoy significant clinical autonomy within a supportive, collaborative environment

Qualifications

• MD or DO in Internal Medicine or Family Medicine
• Board certified or board eligible
• Preference for candidates with outpatient experience in high-need environments, such as health centers or home care
• Interest in population health and health equity
• Proven ability to work effectively in collaborative care settings
• Comfort with independent practice across varied care environments
• Eligible for Massachusetts medical license and DEA

For more information about this opportunity, or to apply, please send your CV to Michele Gorham, Senior Physician Recruiter, at View email address on click.appcast.io

Physical Requirements

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Mass General Brigham Community Physicians, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.