

Delivers primary care disease management for 19-30 follow-up patients per week in community and post-acute settings, being onsite to address post-acute care issues and implement protocols that reduced readmission significantly. Screens 41+ times per month for depression and cognitive change using PHQ-2, PHQ-9, and Mini Mental Examinations, then translates findings into treatment plans and adjusts 11-20 medication plans per week, with patient teaching. Strengthens continuity of care through lab interpretation, imaging review, and prevention focused counseling.