Our Care Management Team services bridge the gap between ambulatory, acute, post-acute care settings and primary care providers, for at-risk patients through case management, care coordination, chronic illness management, patient advocacy, and patient education
Risk Stratification – Care Managers utilize a population health platform to analyze patient characteristics such as chronic disease burden, utilization, and costs. This allows providers to collaborate with the patients and their care team to predict the likelihood of negative health outcomes. Risk stratification tools are essential for directing patients into appropriate Care Management Programs for the development of personalized care plans, engagement of appropriate resource collaboration and overall patient management.
Care Management programs include:
- Care Coordination and Disease Management - Care management services are provided to those who are at risk for or have chronic medical conditions that require assessment and coordination of resources. A multi-disciplinary, continuum-based approach to care delivery provides proactive, population-focused lifestyle risk reduction strategies that follow evidence-based practice guidelines.
- Complex Case Management - Complex care managers work as part of a multidisciplinary care team to improve patients’ self-management skills, increase patients' adherence to treatment plans and provide coordination of care and services to patients who have experienced a critical life event or diagnosis.
- Transitions of Care - The transitions of care team collaborates with physicians, treatment facilities, and family members regarding the plan of care and ongoing care coordination for patients to facilitate safe, planned transitions for patients moving between inpatient and outpatient, emergency, and post-acute care settings. Transitions of Care services are established to directly impact length of stay within acute and post-acute patient settings, decrease in hospital readmissions, and decrease in post hospitalization ER utilization.
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