Currently seeking a Primary Care Physician with experience treating patients with multiple chronic diseases who truly believes in the value of a team oriented Patient Centered Medical Home (PCMH) model. The Primary Care Physician participates as a part of a comprehensive multi-disciplinary team providing wrap around care to patients in a program designed to educate, empower, and improve the health of patients. This physician is also responsible for helping develop transitional care plans for patients being discharged from hospitals, ERs, skilled nursing facilities, and any other venue that requires transitional care. This in turn lowers unnecessary ER utilization, inpatient utilization, specialty utilization, and readmissions while increasing the quality of care delivered. The Primary Care Physician provides physician services including counseling patients regarding the most appropriate setting to meet their healthcare needs, performing diagnostic evaluations and treatment, providing the appropriate information regarding specialist services, and end of life programs. Special attention is given to the PCMH model, evidence based protocols and screening, and working as a collaborative team that includes social workers, behavioral health therapist, clinical pharmacists, and dietitians to educate and empower our patients to make correct healthy choices.