Provides direct patient care to and assists with care coordination of Primary Care patients within the Patient Aligned Care Team (PACT), supporting services and clinics throughout the health care system.
Provides direct patient care to Primary Care patients in accordance with Primary Care standards and recommended practices/guidelines.
Gathers additional data (face to face or via phone) related to patient needs for treatment determination of PACT.
Participates in PACT performance measure activities such as, but not limited to, non-complex 2-day post-discharge calls, clinical reminder compliance, aspects of chronic disease management.
Participates in daily and/or weekly PACT huddles.
Assists with coordinating care of patients, including patients consulted through Clinical Video Tele-Health visits.
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