SERVICES

Chronic Care Management

Patients and their caregivers will gain a team of dedicated health care professionals. Monthly care plan review call with patient and/or health care surrogate to review medications and health management goals, including physical, mental, cognitive, psychosocial, functional and environmental factors

What's included:

Patients and their caregivers will gain a team of dedicated health care professionals who can help them plan for better health and stay on track
Monthly care plan review call with patient and/or health care surrogate; the plan will help support the patient’s disease control and health management goals, including physical, mental, cognitive, psychosocial, functional and environmental factors. We will also keep track of referrals and community services.
Weekly/bi-weekly/as-needed communication for patients with higher complex conditions
Dedicated access to a CCM Specialist & Registered Nurse for all medical needs

Behavioral Health

A dedicated Behavioral Healthcare Manager, with specialized training in Psychology & Behavioral Health, will be working with patients at home and in partnered facilities to promote positive mental, social and behavioral well-being

What's included:

A dedicated Behavior Healthcare Manager
Behavioral Healthcare Manager following up proactively and systematically
A continuous relationship with the patient and family/caregivers
Face to face individualized sessions with patient
Medication management
Brain & social stimulation to sustain and/or improve overall cognitive function
Collaboration with Psychiatry

Remote Patient Monitoring

RPM involves the use of connected electronic tools to record personal health and medical data in one location that is reviewed by a provider at a different location. RPM enables clinicians to observe patients in near real-time, gather necessary data, and make adjustments to improve care outcomes. This type of continuous tracking is helpful for patients with ongoing care needs, such as those with diabetes, heart conditions, asthma, hypertension, mental illness, and, more recently, long COVID, that is, the long-lasting symptoms following COVID-19 infection and recovery.

Remote patient monitoring (RPM) outcomes have been the subject of extensive research. The ability to monitor patients’ blood pressure, weight, or heart data continuously allows physicians to catch risky conditions before they get worse or become critical. This intervention helps reduce clinical workload, hospital visits, and resulting health care costs.

Readmission Prevention

The Readmission Prevention Program aims to provide at-risk patients with world-class clinical care to greatly decrease the likelihood of returning to the hospital.

What's included:

A licensed Medical Provider who is dedicated only to this program
Medical Provider follows up proactively and systematically
Collaborated care with hospital
Proactive assessments.
RPM device for RP team to track and monitor chronic & acute conditions around the clock

Transition of Care

Patients and their caregivers gain a specialist that will help our patients navigate the facility transition system. From start to finish, we will assist with finding appropriate short and long-term accommodations for our patients and/or their loved one. We will remain involved to ensure you are receiving the best possible care as we navigate the transition system together.

Concierge Care

To ensure we provide the most comprehensive approach to your healthcare plan, we partner with our local hospitals, nursing homes, rehabilitation centers and other facilities to deliver your concierge care, wherever you are. This concierge level care ensures the communication gap bridged with your medical group, specialty care, family, caregivers and ALL coordinated care involved in your health goals.