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For patients that are unable to come to the office—in hospital, SNF, LTC or homebound, PCP will engage with the transitional care team and others including case managers, acute and transitional-care physicians, and other resources that may be available depending on the market.
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We are an outcomes-focused, value-based organization and for their panel of patients, the following metrics are regularly measured to help PCP’s become successful and reach partnership status: patient admissions/thousand, using between 18-21 appointment slots per day (each new patient count for 2 slots, follow-up patients 1 slot), CGCAHPS (patient experience), clinical gaps closures, and medical cost measures.
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The Primary Care Physician (PCP) in our organization demonstrates:•Accountability for outcomes: The PCP demonstrates accountability for outcomes, strong clinical care, and cost-effectiveness for each patient in their panel of up to 450 patients.
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The Primary Care Physician (PCP) is a licensed/Board Certified/Board Eligible trained professional in internal or family medicine who plays a key role as part of the clinical operations team providing direct patient care and providing assessments primarily in the ambulatory health care center setting, or occasionally in acute care, nursing homes, skilled nursing facilities (SNF) and home settings depending on the nature of the assignment.
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The PCP is responsible for assessment, diagnosis, treatment, management, education, health promotion and care coordination and documentation for patients with acute and complex chronic health needs.
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The responsibilities include but are not limited to: geriatric assessment, medical history, physical exam, diagnosis and treatment, development of the plan of care, health education, specialty referrals, case management referrals, follow-up and clear documentation according to ChenMed standards for quality, service, productivity and teamwork.
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Provides services supporting a continuum of care from prevention to diagnosis and treatment to appropriate referral and follow-up for simple to moderately-complex workload that can be appropriately managed in a primary care outpatient environment.
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ChenMed, a physician-led and mission-driven, primary care organization, is currently one of the most successful full-risk Medicare Advantage providers in the nation and has a vision to be America’s leading primary care provider, transforming care of the neediest population.
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Accountability for outcomes: The PCP demonstrates accountability for outcomes, strong clinical care, and cost-effectiveness for each patient in their panel of up to 450 patients. The PCP independently provides care for patients with acute and chronic illnesses encountered in the older adult patient.
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In order to achieve our vision and deliver our mission, we need the best primary care providers that are seeking to fulfill purpose and personal opportunity and join the ChenMed family. We’re different than most primary care providers.
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The PCP leads their care team consisting of care promoter (medical assistant), care facilitator, and care coordinator for patients able to come to the office. Coaching for health: The PCP acts as a health coach, rather than just a consultant for sickness, by helping patients set short and long-term health goals, partners with the patient to work toward the goals, and frequently follows up on those goals on the path to improved health for their patients.
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Our mission is to honor seniors with affordable VIP care that delivers better health. Self-Care — A PCP can take the best care for their patients when they are adequately caring for themselves.
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