Cardiovascular Kidney Metabolic (CKM) Physician Assistant II

Site: Mass General Brigham Community Physicians, Inc.

 

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The Population Health department is developing a Multidisciplinary Cardiovascular-Kidney-Metabolic (CKM) Compass Program to proactively identify and manage patients with CKM in our value-based care risk contracts.

The program goals are to ensure (1) appropriate and timely identification of individuals with CKM and (2) ensure timely, guideline-indicated clinical evaluation and treatment of the spectrum of CKM disease states with the goal of improving outcomes for our patients. The PHSO CKM Compass program is a central program providing episodic care to complement longitudinal patient-provider relationships.

The Physician Assistant works in partnership with the team toward the primary goal of ensuring the effective delivery of care of patients with CKM-associated diseases, supporting the achievement of patient and organizational goals. Primary responsibilities include clinical assessment, evidence-based CKM-disease management and protocol development, clinical support for patient navigators, and coordination of care with multi-disciplinary teams to best support patients.

 

Job Summary

The Opportunity

The Physician Assistant will see patients remotely and focus primarily on the following areas: CKM-associated disease treatment optimization, mitigating preventable hospitalizations and ED visits, appropriately capturing and documenting patients’ hierarchical condition categories (HCCs) as clinically indicated, and closing quality gaps via clinical support to programs inclusive of virtual visits with patients.

Clinical Oversight and Insight

- Serve as a clinical practitioner for the multidisciplinary CKM program team
- Support patients with heart failure after discharge from the hospital or emergency department. Determine appropriate support for each patient and is expected to be the clinical lead for diuretic titration and management until the patient is on a stable regimen or is transitioned to their longitudinal care providers
-Provide clinical oversight of day-to-day team functions (including refinement of protocols, procedures, and policies)
-Provide both direct patient care, education, and counseling with CKM.
-Serve as an escalation pathway for CKM navigators.
-Assist the CKM team in development, optimization, and dissemination of care pathways, perform PDSA and other process improvement tools

Clinical Responsibilities

-Implement, support, and coordinate the delivery of care to patients being treated within the CKM program without direct supervision
-Prescribe medications and place orders as needed based on GDMT, diuretic management, and other related conditions as part of comprehensive care management
-Interpret, clarify and evaluate any medical and related laboratory questions that may arise during management of patients who are in the CKM program
-Communicate with navigators, pharmacists, program managers, and physicians
-Order, obtain, and manage test results and patient vital signs
-Manage and triage patients new to the CKM program
-Provide direct care, counseling, and teaching to a designated patient population
-Participate in the development of the CKM program including protocol and care pathway development.
-Participate in the assessment, development, implementation, and evaluation of quality improvement programs, standards of practice, and policies and procedures.
-Document and report all clinical interactions and interventions in appropriate channels.
-Supervise and verify the accuracy of all work completed by supportive personnel assigned to the program.
-Evaluate and analyze the patient's response to therapeutic interventions
-Seek and maintain personal knowledge regarding CKM and associated problems in order to provide accurate resource information to patients.
-Answer telephone calls and messages from patients, family members and clinical staff promptly
-Attend risk capture training
-Complete review and documentation of patient conditions in accordance with PHSO risk capture team guidelines and best practices
-Use standardized tools for risk capture i.e. BPA in Epic, etc.
-Maintain compliance with MGB billing standards and bill for activities via required billing pathway
-Maintain all certifications/licensure