Chronic Care

Services Overview

Our chronic care solution can be particularly beneficial in helping support the care of people living at home with multiple morbidities. By making it easier to pro-actively address health needs, substantial improvement in the quality of life for the individual and the family can be realized.

Our service is designed to engage patients in the comfort of their own home with coaching and consistent follow up, enabling the management of excellent long-term care in the most cost effective manner possible.

We partner with Health Plans, Physician Medical Groups, Home Health and other providers to fill their gaps in long-term care specifically with respect to resource constraints, patient risk stratification, effective intervention and actionable data.

Our patent pending solution addresses the individual care complexities of each patient by incorporating their disease states, chronic co-morbidities, psycho-social and other risk factors into a single assessment tool. Automated and personalized wellness checks listen for new or worsening symptoms and track leading indicators to recommend intervention or increased levels of care utilizing our five key solution elements.

High-touch, High-capacity Patient Outreach

Registered Nurses personally reach out to the patient or the patient’s authorized representative within 24 hours of referral.

Personalized Co-Morbid Health Assessment

RNs create a customized care path incorporating ALL of a patient’s co-morbidities and key psycho-social health determinants. A personalized care plan is established from our initial assessment and review of patient history.

Persistent Patient Engagement

Friendly, automated calls are conducted to efficiently “check in” and listen for new or worsening symptoms, tracking leading indicators for intervention or recommendations for increased levels of care.

Efficient and Effective Alert Management

Health alerts validated and triaged by RNs identify patients at risk and the family or healthcare provider is notified by phone, email or text for timely and appropriate intervention.

Data Analysis and Reporting

Data collected from patient engagement generates actionable analytics and reports for transitional care improvements.