Codman Square Health Center 637 Washington St Dorchester, MA 02124 617-825-9660 codman.org POSITION: Medical Director for ACO Dvlpmnt & Population Health DIVISION: Clinical REPORTS TO: Chief Medical Officer DEPARTMENT: Medical Department FLSA: Exempt FT/PT: 0.2 (8 hours weekly) Position Summary: Codman Square Health Center s mission is to be a resource for the physical, mental and social well-being of our community. The Health Center strives to deliver services that supports the achievement of its mission, while creating a sustainable care model that adapts to the changing healthcare environment. Through continuous quality improvement, the Health Center strives to provide high quality services and maintain optimal patient safety. Reporting to the CMO, the Medical Director for ACO Development & Population Health (MDA) works in conjunction with the Director of ACO and Care Management to lead the Health Center s ACO planning and implementation efforts and collaborates with the Boston Accountable Care Organization (BACO) and Health Center Leadership to develop a plan for transition to a value-based care model. Building on existing Health Center Patient Centered Medical Home (PCMH) and Team Based Care initiatives, and with the support of the PCMH transformation team, the two Directors are responsible for the Health Center s performance in the Boston Accountable Care Organization (including quality, financial, and other performance measures), maintenance of PCMH Recognition, and alignment of these and other quality improvement initiatives with the Health Center s organizational goals. The MDA represents Codman on the BACO Quality committee (QCITI), attends all BACO leadership meetings as requested by the CMO, and is responsible for overseeing the development of the ACO and PCMH transformation model, goals, strategies, and workplan. The MDA is a Member of the Health Center s ACO strategic planning committee, and leads or co-leads the Health Center s Practice Transformation Committee and select ACO working groups; these working groups are responsible for implementing care models that will enable the Health Center to achieve ACO related performance goals. Care models will include, but are not limited to, primary care-based complex case
management, chronic disease management, care transitions, care coordination, reduction of ED utilization, and wellness and prevention initiatives. In addition, the Directors will partner with the Senior Director of Behavioral Health (SDBH) to develop Integrated Behavioral Health Programming that supports the primary care team based care model and achieves the ACO BH performance expectations, including coordination with BH Community Partners. Primary Responsibilities: 1. Leadership Articulate the organization s mission, vision, strategy and priorities. Facilitate team work, demonstrate trust and confidence in staff, and acknowledge the contributions of others. Demonstrate honesty in interactions and accountability in behavior. Model creativity and innovation. Participate in organizational strategic planning (Clinical, Operational, and Fiscal) with a focus on the medical model and clinical innovation. Chair ACO Meetings. Work collaboratively and support the work of other medical, nursing, behavioral health, and operations leaders in fulfilling the organizational strategic priorities. Provide effective interactive communication. 2. Strategy and Planning In collaboration with the Director for ACO and Care Management o Develop a sustainable work-plan to achieve ACO performance outcomes to include, but not limited to: Development and Documentation of implementation plans for Care Models for Complex Care Management, care transitions, chronic disease management, care coordination, reduction of ED utilization, and prevention initiatives. Development and/or oversight of risk stratification methodology. Development and/or oversight of risk based coding. Development and/or oversight of out-of-network referrals Monitoring of outcomes and analytics Identifying, building collaborative partnerships, and developing appropriate workflows with BH and LTSS community partners. o Member and co-facilitator with the Director for ACO and Care Management of the Health Center s ACO strategic planning committee. o Troubleshoot barriers and challenges and develop improvement strategies. o Cultivate partnership with BACO and Boston Health Net (BHN). Participate in BACO and BHN ACO Meetings Coordinate efforts with BACO and BHN to achieve ACO desired outcomes, coordinate care, and ensure cultural alignment within network. In collaboration with PCMH Transformation Team, and the Director for ACO and Care Management, develop a work-plan to maintain NCQA PCMH recognition and related PCMH recognition (e.g. PCMH Prime).
3. Implementation In collaboration with Director for ACO and Care Management: o Facilitator and member of ACO strategic planning committee. o Leader & Facilitator of the Health Center s Practice Leadership Committee and select ACO working groups. In collaboration with Director for ACO and Care Management and the PCMH Transformation Team: o Responsible for oversight and implementation of ACO, population health, and PCMH transformation work-plans, including: Care Models for Complex Care Management, care transitions, chronic disease management, care coordination, reduction of ED utilization, and prevention initiatives. Development and/or oversight of Risk stratification methodology. Monitoring of outcomes and analytics Partner with Medical Director for the Practice and Senior Director for BH to finalize workplan and implement medical and BH provider protocols, processes, and workflows. Partner with Medical Director for the Practice to chair and facilitate the medical practice transformation meeting. Work collaboratively with the other Medical, Nursing, Behavioral Health, and Operations Leaders to implement models for ACO restructuring/improvement initiatives to ensure sustainability. Collaborate with Informatics Leadership to ensure IT applications support transformation. Serve as point person interfacing with Medical Directors, Nurse Leadership, BH Leadership, and Operations leadership to ensure integration of care management teams into primary care practices Promote Team Based Care model. 4. Performance and Evaluation In collaboration with Director for ACO and Care Management and PCMH Transformation Team o Responsible for Health Center achievement of annual BACO Funds Flow Requirements, including: Improving Quality Scores. Improving risk-based coding Decrease out-of-network utilization. Decrease hospitalizations for patients in Complex Case Management Decreasing avoidable ED utilization by CSHC patients. Oversee evaluation framework for ACO & PCMH initiatives. Work collaboratively with the PCMH transformation team, the provider champion for informatics, and the information systems applications team to develop and monitor analytics and performance. Work collaboratively with the other Medical, Nursing, BH, and Operations Leaders to achieve practice outcomes. Monitor and Evaluate ACO restructuring/improvement initiatives to ensure sustainability. In collaboration with Medical Director for the Practice, responsible for Oversight of Provider Performance on Quality Measures. 5. Mentorship, Training & Communication Responsible for Mentorship of Clinical Leaders on ACO goals and workplan.
In collaboration with Medical Director for the Practice, responsible for for oversight of Training of Providers and Clinical Support Teams as part of workplan. Expected to leverage internal, BACO, and BHN subject matter experts. Responsible for developing and delivering on ACO Communication Plan to Providers and Care Teams Troubleshoot barriers and challenges and develop improvement strategies to address them. 6. Supervision Recruit, hire, mentor, manage, and evaluate assigned Staff. Provide ongoing support to supervisees, manage workload and ensure they have the tools and resources to be successful. 7. Finance and Administrative Maintain ACO management budget. Regularly report on clinical and financial performance measures. Participate in grant writing to support ACO development. Participate in all BACO and BHN meetings as assigned. 8. Other duties as assigned Qualifications and Skills: Education: MD, DO, or NP licensed to practice medicine in the state of Massachusetts and a practicing clinician at Codman Square Health Center. Preferred/Desirable: Masters in Public Health, Business, or related field preferred Project Management Experience Grant Writing Experience Experience: 4 years of clinical experience preferred 1 year of management experience preferred Experience working in the Primary Care setting Competencies, Skills, and Attributes: Excellent interpersonal skills and ability to work collaboratively
Management skills, including ability to prioritize and set goals with team members Project management and analytical problem solving skills and strategic acumen Excellent written and verbal communication Ability to work with diverse population Skilled at coaching Creative problem solver Ability to adapt to changes in healthcare delivery at local and systems level Extensive knowledge of healthcare systems and community resources Ability to leverage systems and resources for improved patient outcomes Results oriented with the ability to prioritize and manage various projects Strong organizational and time management skills Familiarity with process mapping and work flow analysis tools Sound clinical knowledge and familiarity with the health care delivery systems Working Conditions and Physical Effort: Regular and reliable attendance is an essential function of the position. Internal Applicants Only: Send resume and internal application to human resources CSHC is an Equal Opportunity Employer, M/F/D/V encouraged to apply