A Primary Care Model Designed Differently
Effective senior care extends beyond the number of patients seen in the clinic each day. Sutter Senior Care creates the flexibility for clinicians to respond to changing patient needs and proactively manage a defined patient population.
Practice highlights include:
- Monday-Friday outpatient practice
- Approximately 10 pre-scheduled appointment slots per day, with a mix of 30- and 60-minute visits
- 60-minute new-patient and complex visits
- 30-minute routine follow-up visits
- Flexibility to accommodate additional same-day visits when urgent patient needs arise
- Same-day and next-day access incorporated into the care model
- Interdisciplinary, team-based approach to complex senior care
- Focus on prevention, chronic disease management, medication safety, care transitions, and quality of life
- Opportunity to help develop and shape a growing senior-focused service line
Panel-Based, Team-Oriented Care
Sutter Senior Care is structured around shared accountability for a patient population, rather than a traditional visit-volume model.
At full maturity, the Natomas clinic is expected to serve approximately 2,000 to 2,300 patients. A care team consisting of one 1.0 FTE physician and two 1.0 FTE APCs would be accountable for approximately half of the clinic's patient population.
This approach requires clinicians who are comfortable thinking beyond individual encounters and actively managing the health of their patient panel through office visits, care-team collaboration, patient and caregiver communication, and proactive intervention as needs change.
APCs work collaboratively with an interdisciplinary team designed to include:
- Physicians
- Other APCs
- Nurses
- Licensed Clinical Social Workers
- Care coordinators
- Community health workers
- Clinical pharmacists
- Dietitians
- Physical and occupational therapists
- Other clinical and community-based partners
The team structure is intended to address both the medical and social factors affecting a patient's health while supporting coordinated care throughout the aging journey.
APC Responsibilities
- Provide comprehensive, patient-centered primary care for older adults
- Conduct physical examinations, obtain medical histories, and complete comprehensive assessments
- Diagnose and manage acute and chronic medical conditions
- Develop and implement individualized care plans focused on prevention, chronic disease management, and healthy aging
- Develop meaningful longitudinal relationships with patients, families, and caregivers
- Take an active role in panel ownership and the proactive management of changing patient needs
- Prescribe and manage medications with particular attention to medication safety and polypharmacy
- Order and interpret diagnostic testing and laboratory results as appropriate
- Collaborate with physicians and interdisciplinary team members to coordinate comprehensive care
- Support transitions between home, hospital, specialty care, and other care settings
- Help identify opportunities for proactive intervention that may prevent avoidable emergency department visits or hospitalizations
- Educate patients, families, and caregivers regarding disease management, medications, preventive care, nutrition, healthy aging, and self-management
- Participate in team huddles, population-health efforts, quality improvement, and initiatives designed to improve patient outcomes
- Maintain accurate and timely documentation consistent with clinical and regulatory requirements
- Support APC students or developing team members as appropriate
- Contribute to the continued development of Sutter Senior Care and its value-based approach to caring for older adults
Call
Sutter Senior Care uses a shared call model. As the program reaches full maturity, shared call is expected to include evenings, weekends, and holidays.
Ideal Candidate
We are looking for APCs who want to practice relationship-centered, panel-based primary care and who understand that excellent care for older adults often happens beyond a traditional office visit.
The ideal candidate enjoys building long-term relationships with older adults and their families and is comfortable managing patients with multiple chronic conditions and complex medical, functional, and social needs.
Candidates should value flexibility, proactive patient management, shared decision-making, and interdisciplinary collaboration. They should be comfortable assuming meaningful responsibility for a patient population while partnering closely with physicians, other APCs, nurses, social workers, pharmacists, care coordinators, and other members of the care team.