This role provides physician services to include patient consultation, primary management of people living with HIV  and other chronic infectious diseases.  These services include developing a diagnostic and treatment care plan, counseling patients regarding the most appropriate setting to meet their healthcare needs, educating them about their illnesses, advising appropriate specialist services, and end of life programs.  The role functions as a part of a large, integrated care team with the goal of providing whole-person care in the outpatient setting.

Duties and Responsibilities

• Provide care for people living with HIV  and associated medical conditions and patients with other chronic infectious diseases.
• Provide outpatient care consultation and ongoing treatment of chronic infectious diseases.
• Deliver comprehensive care for patient panel, including management of chronic diseases directly or through collaboration with primary care physicians and specialist.
• Work in a team environment (with social work, care management, integrated behavioral health, pharmacy, nutrition, health education etc.), process feedback, and facilitate open discussion.
• Implement plans of care in collaboration with the patient, their family and other team members.
• Develop strong transitional care plans and able to keep track of paneled patients along the whole continuum of care including hospital discharges, ER, skilled nursing facilities and home care.
• Vigilant in keeping track of patients and their disease processes to avoid ER visits, admissions to the hospital and readmissions.
• Assist with educating patients regarding their chronic diseases and healthy choices.
• Assist with the education and discussion of chronic disease progress and advanced directives.
• Practice evidenced based medicine in accordance with the PCMH model of care.
• Assessment, planning and coordination of care for HIV/AIDS patients.
• Able to work with and lead a team (with social work, case management, behavioral health, pharmacy, nutrition, etc.), process feedback, and be open to discussing and implementing plans of care from other members of the team.
• Develop strong transitional care plans and able to help keep track of paneled patients along the whole continuum of care including discharges from the hospital, ER, skilled nursing facilities/nursing homes, and home care.
• Treat acute exacerbations of chronic conditions within the AbsoluteCare center, i.e. Lasix for CHF, IVF for Dehydration/Renal Failure, IV antibiotics for various infections, Nebulizer/Solumedrol for COPD/Asthma etc. Possess a comfort level and the knowledge to differentiate when exacerbation can be treated within AbsoluteCare and when a higher level of care needed.
• Accept same day/next day or urgent appointments for patients from home or discharged from the hospital/ER/skilled nursing facility in need of intensified physician or case management/social work services to ensure acute episode has resolved and the patient is not admitted/readmitted.
• Vigilant in keeping track of patients and their disease processes to prevent ER visits, admissions to the hospital, and readmissions.
• Understand the PCMH model of care as pertains to specialist care, only utilizing this higher level of care as needed, and not a substitute for a well-trained primary care physician with evidence based clinical skills.
• Educate members on chronic disease progression and the need for advanced directives where applicable
  Practices evidenced based medicine and in accordance with the PCMH model of care.
• This job description is subject to change at any time.