Population Health Management and Care
Our mobile integrated healthcare services include:
Transition-to-home services and 24/7 program-specific niche intervention services for home hospice patients, their families and caregivers when changes in patient condition occur or when unexpected needs arise. Sentinel specialist providers conduct rapid event assessments and immediate communication with the patient’s normal hospice team member in order to enhance on-scene support and allow an informed decision by the hospice team as to whether an off hours or unplanned visit is needed.
Experience-focused transition-to-home services. These services can include transport to residence, prescription fulfillment and delivery, medication reconciliation, reconnecting the patient with family and social supports, communicating with the patient’s primary physician to re-establish routine surveillance and care, follow-up visits or call center telephone contacts to ensure successful reintegration in the home, identification of patient experience gaps, and more.
Longitudinal interprofessional medical care for patients in their homes. Continuum is a family of medical care programs that feature multiple providers working within an interprofessional team who design patient-specific care plans and then care for previously deteriorating patients immediately post-discharge from a hospital in order to prevent relapse and avoidable E.D. visits.
Specialized care navigation services for patients with unusually frequent 911 ambulance requests or abnormally recurrent presentation to emergency departments.