Manage chronic illnesses in a complex elderly population with multimorbid conditions focused on wellness, avoiding unnecessary hospitalizations and ER visits, providing patient education about disease processes, improving overall quality of care, and increasing patient satisfaction in the healthcare system Document timely with an added focus on closing HEDIS quality gap measures and recapturing HCCs Engage new patients enrolling in the program with a comprehensive geriatric focused initial assessment that includes functional eval, social and safety assessments, cognitive screening and mental health assessments and more Triage, diagnose, and treat patients on an urgent basis in home with an array of equipment and medications Order and interpret appropriate tests including x-rays, labs, and EKGs to diagnose, prescribe and treat within the provider’s scope of practice and consistent with the standards of care Start treatment in the home at the point of care Collaborate with patient’s PCP and specialists as needed Implements HEDIS measure campaigns and other quality initiatives to ensure the highest standards of care and to promote the improvement of care management and delivery