We carve out the highest risk patients and give them dedicated clinical support. This population of patients consists of people who have three + chronic conditions including COPD, CHF, CAD, Diabetes and Hypertension. Our average member has six.
We work to catch patients who might not need to be admitted into the hospital with the immediate availability of an outpatient visit. By keeping family members out of the hospital, we help them spend more quality time at home.
We leverage our clinical teams to catch people who are discharged from the hospital and help them land safely in the arms of the PCPs. This 30-day focused intervention ensures the patients understand the Plan of Care and that the PCPs receive post-discharge patients at maximum stability.
Some patients can be discharged from the Hospital earlier IF an outpatient appointment is immediately available. We can help facilities with get earlier discharges by being able to see the members immediately. This helps lengths of stay and
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