The highest-risk patients with multiple chronic conditions and many issues related to social drivers of health require a fundamentally different care model. Solutions that only address a single co-morbidity or piece of the cost base are insufficient and often create misaligned incentives. Based on our research, most primary care physicians agree that a small subset of the highest-risk patients have needs that are difficult to manage in a 10-15 minute office visit.
Our care teams provide supplemental primary care within a patient’s home, including after-hours clinical support. These teams are physician-led and provide medical, pharmaceutical, behavioral, social and palliative care.
Our care model is designed to work alongside and complement existing local providers, not disintermediate them or the critical relationships they have with their patients/health plan members. Our legacy as a provider and medical group gives us unique sensitivity to working with local primary care physicians (PCPs) and specialists.
- Medication Management
- Post Discharge Follow-up
- Behavioral Health
- Advance Care Planning and Palliative Care
- Post-Acute Care
- Annual Wellness Visits
- Education and Resources
- Health Screenings
- 24/7 Access
- Care Coordination
- Accurate Coding and Documentation
- Coordination of Social Services
- Caregiver Support
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