Provides medical care to program participants in collaborative practice with a physician.

JOB RESPONSIBILITIES

Serves on the PACE interdisciplinary team. Performs comprehensive history and physical examinations of participants - initial assessments, six month assessments, and unscheduled assessments. Develops, revises and keeps current treatment plans for participants. Integrates clinical treatment plans with the overall plan of care for each participant. Collaborates with the physician, nurses and IDT to meet the needs of participants at home, in the clinic or in a nursing facility to prevent serious acute illnesses that require inpatient treatment. Evaluates and treats participants with acute, episodic and chronic illnesses, collaborating with the physician in the management of patient care. Prescribes medications as indicated and monitors utilization. Refers participants to and monitors care provided by medical specialists and other primary care providers. Refers participants to inpatient physicians for necessary hospital admission, Monitors each admission for service utilization and optimal clinical outcome. Advises the IDT and hospital case managers about discharge planning. Manages the care of home-bound participants and participants in nursing facilities through regular visits and telephone contacts. Visits homebound participants as scheduled and visits other participants at home as needed. Oversees care provided by visiting nurses. Communicates changes in participant status to IDT members and notes changes in medical records. Educates participants, staff and caregivers on health care issues. Participates in family conferences, team meetings, committees and work groups as required. Serves on the Compliance Committee and PACE Management Team. Participates in the Quality Assurance and Performance Improvement program. Participates in the coordination of a 24-hour care delivery system, sharing call with the physician. Completes documentation in the medical record as required. Maintains a safe and clean working environment Adheres to infection control policies and procedures. Utilizes the protocol entitled Clinical Guidelines in Family Practice (Uphold and Graham). Acts within the scope of his or her professional license.