You will primarily be a clinic-based primary care physician who will: Assess patients’ full spectrum of needs at least annually, including medical psychological, social, financial, and environmental; Understand patients’ values and goals and thoughtfully incorporate them into each care plan; Guide patients with multiple chronic medical conditions and their caregivers through complex medical decision making; Proactively manage patients’ health through preventive care as dictated by geriatric medicine guidelines as appropriate for patients age, prognosis, and medical complexity; Manage both acute and chronic disease states; Guide management of transitions of care; Actively quarterback patients’ care through proactive conversations with other physicians, providers, and caregivers to ensure alignment of treatment plan. Facilitate advanced care planning conversations and provide palliative care support to patients as appropriate; Build deep and strong relationships with patients and caregivers, to help them achieve the health outcomes that are most important to each person; You’ll act as the day-to-day clinical leader of your multi-disciplinary team, supporting team members in providing holistic care to our patients.