We work with your other specialists to create one care plan that can encompass all your healthcare needs.
- House Calls/Primary Care
- Chronic Care Management
- Transitional Care Management
- Internal Medicine
- Palliative Care Medicine
Patients that are home bound and require a visit for a non-urgent medical need receive a primary care visit with a clinician.
Our team will follow up with you throughout our case coordination services to reinforce the care plan and patient’s goals.
Our transitional care program provides assistance to Integrated Delivery Systems, Medical Groups, Accountable Care Organizations (ACOs) and Health Plans to reduce inappropriate utilizations and hospital readmissions.
Our visit includes:
- Medication review, reconciliation and “real-time” adjustments as needed
- Assessment if patient needs home medication delivery
- Functional/safety/skin /caregiver issues and needs
- Cognitive status
- Pain issues and pain management with recommendations to pain management specialty
- Assessment of patient prognosis, insight and expectations
- Engage patient in their healthcare and personal goals
- Advance Care Planning, directives and discussions and completion of the POLST
- Clinical status of primary diagnosis intervention as appropriate
Our Comprehensive approach includes face to face clinician visits, active discharge planning, and continuity of services.
Our goal is to provide access to a sick and frail population regularly improving the patient’s quality of life and avoid ER visits, inpatient visits and readmissions.
Palliative care can help when a patient wishes to focus on quality of life while they still pursue medical treatments.
Palliative medicine is designed to manage your symptoms, pain, and the stress of a serious illness.
The goal is to provide understanding and education of expectations of their illness and help them address their needs and wishes.