Physician - High Risk Populations; MD​/DO - Bridge Program

Overview

Central Health’s Department of High-Risk Populations encompasses several innovative programs at the cutting edge of heath care that focuses on providing comprehensive, holistic care to underserved and marginalized populations in our community. As a member in the High-Risk Populations (HRP) healthcare team, the HRP Physician will have the opportunity to work among the different programs, primarily in the Medical Respite program as well as other programs like the Bridge Program.

Medical Respite is a unique program that provides a place to recover while recuperating from an acute illness, typically for those experiencing homelessness. While in the program, they have an opportunity to improve their health literacy and work on benefits, housing, and other social needs. Providers are critical members of the care team that collaborate with the patients and the respite team to support their stay and goals while in the program.

The Bridge Program provides medical care to individuals who are marginalized, many who are experiencing sheltered and unsheltered homelessness. Through unique care models including a clinic which is co-located with other specialists, mobile-street care at locations such as community partners, shelters, or encampments, making care accessible and low barrier is critical. Providers work within an interdisciplinary team to provide comprehensive, holistic care, addressing physical health, mental health and social needs.

A successful candidate will have a strong commitment to health equity, an interest in building partnerships within the community, and compassion and sensitivity in working with marginalized communities. Additionally, a desire to collaborate closely with case managers, community health workers, other healthcare professionals and community partners to coordinate care to navigate and leverage community resources will be paramount to the patient-centered, whole person care for the individuals we serve.

This position aligns with Central Health’s deep commitment to advancing health equity and improving health disparities in our community.

Respite Clinic Specific Functions

• Patient Assessment and Diagnosis:
  Conduct comprehensive medical evaluations of patients admitted to the medical respite program, including taking medical histories, performing physical examinations, and ordering necessary diagnostic tests to identify medical issues.
• Treatment Planning:
  Develop individualized treatment plans based on patient assessments, considering both acute medical needs and underlying chronic conditions, while addressing social determinants of health.
• Medication Management:
  Review and manage medications, including providing instructions on proper medication administration and addressing potential drug interactions.
• Care Coordination:
  Collaborate with other healthcare providers, case managers, and social workers to coordinate care, ensuring patients receive necessary services like mental health support, housing assistance, and benefits navigation.
• Discharge Planning:
  Create discharge plans with patients, identifying necessary follow-up appointments, connecting them to community resources, and facilitating a smooth transition back to their living situation.
• Clinical Oversight:
  Provide clinical supervision to other medical staff within the medical respite program, including nurses and nurse practitioners, ensuring quality care delivery.
• Advocacy:
  Advocate for the needs of patients experiencing homelessness, working with community partners to address systemic barriers to healthcare access.
• Review Program Referrals:
  Assist referral nurse in evaluating referrals for medical appropriateness or eligibility for the respite program as needed.

Bridge Clinic and Mobile/ Street Specific Functions

• Patient Assessment and diagnosis:
  Working in a multidisciplinary team, conduct comprehensive medical evaluations of patients admitted to the medical respite program, including taking medical histories, performing physical examinations, and ordering necessary diagnostic tests to identify medical issues.
• Direct patient care across settings:
  Provide care in the medical respite clinic, bridge clinic, and mobile street medicine settings.
• Compliance:
  Ensure all tasks related to patient care, patient administration, and related duties comply with regulatory and accreditation standards including Joint Commission and Central Health Standard Operating Procedures, Policies, and Procedures.
• Clinical impact:
  Directly improves patient well-being through accurate and timely diagnosis and delivery of high-quality medical care.
• Coordination:
  Coordinate with primary care providers, specialists in hospital, post-acute, outpatient and community settings.
• Communication:
  Communicate effectively with patients, families, colleagues, and healthcare professionals.
• Care planning:
  Plan and coordinate daily care with Central Health’s care team members.
• Education and teaching:
  Engage, lead, and supervise learners affiliated with Dell Medical School, and…