Job Description
At PopHealthCare, our mission is simple – help higher risk individuals live healthier lives (www.pophealthcare.com). We are bold innovators, dedicated to making a difference and we hire wicked smart people! We need sharp and nimble BOARD-CERTIFIED PHYSICIAN! Our Physicians are responsible for providing health care to patients enrolled in the CareSight Program in their home. The Physician will join a care team that consists of Nurse Practitioners, Registered Nurses and Care Coordinators and works closely with the patient’s primary care physician.
We are currently recruiting a FULL-TIME BOARD CERTIFIED PHYSICIAN to join our team in the HOUSTON, TX area.
SUMMARY:
CareSight teams are a multi-disciplinary team that provides comprehensive care to members with chronic disease in their homes. We collaborate with the members primary care provider and other specialists to ensure complete wrap around care. Areas of focus include chronic disease management, acute visit needs, transitions of care, and preventative care maintenance.
Must have a strong desire to build close relationships with all members of the field and regional teams. Must be committed to working in a collaborative relationship with the members primary care provider. Excellent time management, organizational skills, and strong communication is a must.
Our schedule allows members of the health care team to spend extended amounts of time with patients in their homes. This allows us to address the patient as a whole (physical, social, and emotional health).
The focus of care is on the most medically and socially complex patients, including those that are considered homebound.
JOB RESPONSIBILITIES:
- Delivers cost-effective, high-quality care to assigned CareSight patients
- Completes comprehensive history and physical examination on all enrolled patients in an in-home visit
- Manages medication therapy effectively:
- Reviews and reconciles medications each visit
- Avoids high-risk medications
- Prescribes medication, adjusts dosages, discontinues medications as appropriate
- Administers selected medications in the home (if clinically safe to do so)
- Delivery of home-based care on a consulting and continuing basis
- Collaborate with interdisciplinary team members – including advanced practice providers, registered nurses, social workers, community heath specialists and other members of the CareSight team.
- Communicates closely with patients’ other healthcare providers so that care is coordinated
- Collaborates with NPs, RN’s and patient to determine patient’s risk of adverse health outcomes
- Completes proactive, in-home visits on all INTENSIVE level patients at least monthly
- Completes proactive, in-home visits on all CORE level patients quarterly
- Completes unplanned, urgent, and/or emergent in-home visits as needed to meet patient needs
- Adjusts visit frequency and schedule based upon patient needs
- Responds to calls from the patient, caregiver, CareSight RNs, etc
- Addresses Advance Care Planning proactively; identifies surrogate decision maker (MPOA, Health Proxy, etc)
- Partners with local market leadership, clinical service manager, director of clinical operations, market medical director and other clinical leaders to further evolve care model.
- Collaborates with NP and RNs in the development of an integrated care plan that identifies key patient problems, goals of care, barriers to meeting goals, interventions, activation level, and patient self-management activities
- Communicates effectively with entire care team including the patient’s community primary care provider
- Provides effective patient education using the Teach Back technique
- Documents all patient encounters (in-home and telephonic) per documentation standards
- Participates in clinical case conferences as required
- Participates in on-call coverage for patient care