The Community-Based Clinician brings needed primary and urgent care directly into the home, meeting members where they are and helping support them during some of the most critical points in their care. A key focus is managing transitions of care, especially the important and delicate period following hospital discharge.

Duties and Responsibilities  

Provide community-based medical and care-coordination services for recent hospital discharges.  Manage a small panel of homebound members who require primary care.  Resolve acute issue in the home and clinic or by directing member to most effective and efficient solutions.

• Ability to travel between Prince George County and Baltimore providing care to members in their homes.
•  Acute onset of a new illness.
• Evaluation of acute exacerbations of chronic conditions.
• Shortness of breath without chest pain, change in mental status or new onset hypoxia.
• CHF exacerbations
• Asthma/COPD exacerbations
• Bronchitis/pneumonia
• Hyperglycemia 
• Elevated blood pressure 
• Evaluation and treatment of a variety of infections
• New or worsening aches or pains, wounds, depression and/or anxiety.
• Members we know will go to the ER if not seen today.

Ensure coordination of care to include:

Timely and accurate completion of chart documents.

• Work with Treatment and Triage Nurse to address sick calls and visits requiring Provider management.
• Receive input from the Core Clinical Team (PCP, Care Manager or SW) to define visit goals.
• Communicate important post visit follow up information to Core Clinical Team.
• Collaborate with Integrated Care Team (ICT) members (behavioral health, nutrition, health education) for problem solving and coordination of care.
• Identify and refer to specialty programs when instability or crisis occurs such as: abuse/neglect, interpersonal violence, significant and complex housing, and food insecurity.
• Implement transitional care protocols as part of warm hand offs between internal and external care providers.
• Help patients identify barriers to meeting health and life goals and connect patients with resources to navigate barriers.
• Adjust care plan following guidelines for evidenced based chronic disease management.
• Educate and coach for medication adherence and chronic disease self-management skill development.
• Monitor members at risk of being lost to care and implement interventions to prevent loss.

Education & Experience Requirements:

• This is a Community Based position must be willing to do home visits
• Certified Registered Advance Practice Provider in a field of Adult Medicine with Acute Care experience.
• ACLS certified.
• Ability to take a creative and innovative approach to problem-solving to aid patients in overcoming barriers to care.
• Ability to meet deadlines and manage multiple priorities.
• Effectively adapt and respond to a complex, fast-paced, and results-oriented environment.
• Success using Electronic Medical Records and ability to analyze and leverage their reporting capabilities.
• Excellent computer skills, including knowledge of Microsoft Office.
• Patient-centered focus.
• Familiar with care transitions, strategies for reducing readmissions and chronic condition management interventions.

Preferred qualifications:

• Experience in a Patient Center Medical Home. 

• Experience working with high risk and medically complex patients with multiple comorbidities.