Transitions of Care Physician; MD

Position: Transitions of Care Physician (MD/DO)
Overview

Under the Associate Medical Director of Post Acute and Care at Home Programs, the Transitions of Care staff physician will oversee patient care, manage clinical teams, and provide direct care to low-income and uninsured patients in post-acute settings such as Skilled Nursing Facilities, hospitals, and home visits.

This position's responsibilities encompass acting as an Attending Physician, leading rounds with Advanced Practice Providers in a skilled nursing facility and providing medical care in the home of patients. The staff physician will also collaborate with Nurse Case Managers, Social Workers, Community Health Workers,Physicians, and other healthcare professionals to provide inpatient care in partnership with Dell Medical Schooland coordinate transitions of care and navigation services.

This position models a commitment to Central Health's vision/mission/values to support an unparalleled patient experience and positive clinical outcomes.

Responsibilities

Perform comprehensive physical assessment of patients using observation, inspection, auscultation, palpation and percussion.

Order or execute various tests, analyses, and diagnostic images to provide information on patient’s condition.

Diagnose and treat diseases, disorders and injuries based on patient’s medical history and results of physical assessment and refer patients to medical specialist or other practitioner for specialized treatment.

Prescribe medications and therapies for treatment, preventive care, and contraception.

Instruct patients and their families regarding medical therapies, procedures performed, plan of care, and followup visits.

Direct professional and ancillary health care staff during treatment of patients.

Provide direct patient care in Skilled Nursing Facilities and acute hospital  eligible for appointment to the faculty at Dell Medical School, The University of Texas at Austin, in the Department of Internal Medicine or Department of Population Health.

Oversee and practice medicine specific to home-based care.

Participate in the development, building, and training of electronic health record modules.

Engage, lead, and supervise learners affiliated with Dell Medical School and participate in teaching endeavors with Dell Medical School learners.

Essential Functions Collaborate with APPs, Transitional Care at Home team and the case management team for the Transitional Careat Home program with home visits.

Serve as an attending physician in SNFs.Develop and deliver effective public presentations in partnership with leadership.

Comply with facility and medical staff bylaws for safe patient care in post-acute settings.

Coordinate with primary care providers and healthcare teams for MAP patient care in hospitals and post-acute environments.

Communicate effectively with patients, families, colleagues, and healthcare professionals.

Prepare and provide necessary reports and forms as required.

Coordinate and collaborate with Central Health’s advanced-practice providers for hospital and skilled nursing facility services.

Plan and coordinate daily care with Central Health’s care team members.

Foster collaborative relationships with affiliates, providers, officials, regulatory bodies, patients, and the community.

Work closely with diverse patient populations.

Facilitate effective communication with Case Management/Care Coordination teams to prevent readmissions.

Collaborate proactively for discharge teaching of readmitted/high-risk patients.

Develop, implement, and evaluate service delivery, patient experience, and care management activities.

Exhibit compassion, vulnerability, and empathy when working with employees and patients and advancing

Central Health’s health equity and DEI goals.

Provide patient centered care that is inclusive and…