Services

Program Tiers

Our tiers may adjust to a higher LOC or decrease to a lower LOC upon engagement findings, client progress and our needs based assessment tool.

Low Risk

Disease Management / Stable

( RPM Optional based on appropriateness )

( 0 to 1 qualifying diagnosis )

Average 2-3 months  participation

Health Promotion / Maintenance:

This group includes patients who are stable and moderately healthy. These patients have minor conditions that can be easily managed. The goal for this group is to keep the participant healthy and engaged in the health care system, without the use of unnecessary services. This is an educational tier for the client to address and improve health literacy, address specific needs related to the qualifying diagnosis and promote self care awareness and self directed care of the qualifying diagnosis.

Our health promotion / maintenance plan is a program identified by the participants MR and should include the criteria of a new dx requiring education, new medications requiring monitoring and or education regarding an acute episode related to the qualifying diagnosis.

Goals:

  • To supplement provider education and to monitor for effectiveness in provider POC resulting in interventions before an issue arises, becomes serious and more expensive.
  • Promotion of self management / awareness
  • Compliance with physician POC

Low to High Risk

( 1 to 2 qualifying diagnosis )

Average 3-4 months participation

Disease Management / Stable

( RPM Optional based on appropriateness )

This group of patients have a prominent diagnosis and a co morbidity which is stable. This tier takes a Pro-Active approach toward actions and interventions that facilitate problem identification which has the potential to lead to further health related conditions.

Our disease management program for the stable client is identified by the participants MR and evidenced by the criteria of 1 to 2 qualifying diagnosis. The diagnosis would be ones of which a possibility of greater potential for a less than optimal outcome is noted.

Goals:

  • Education and monitoring for better self-management of the conditions with focus on sign and symptom awareness and symptom management.
  • Disease control. Enhancement of health literacy for optimal self management and optimal outcomes.
  • Compliance with physician POC

High Risk to Catastrophic

( 2 or more Chronic Disease )

Average 6-8 months participation

Chronic Disease Management

This group of clients have 2 or more persistent chronic diagnosis. Multiple co-morbidities may be present. They may have frequent ER or hospitalizations related to the chronic disease.

Our Chronic Disease Management plan is a higher level of care which includes a greater amount of client interaction, CM (Case Management services) provided by a Registered Nurse certified in Case Management, the use of RPM devices (remote monitoring) according to the diagnosis and the integration of paneled disciplines such as LCSW to address BH concerns and or RD services as appropriate.

Goals:

  • Optimize Behavioral change / Increase quality of Life
  • Improvement in ability of self-care practices
  • Prevention of exacerbations Reducing un necessary over utilization of various health care services, including hospital admissions and emergency room visits.
  • Address barriers / Improve clinical outcomes

TOC ( transitions of care )

This group has experienced a recent encounter with an inpatient facility, between facilities, within the community, or from a primary care to a specialist.

Average 0-1 month participation

The transitioning clients are at risk for an adverse outcome due to potential for medication errors, failure to follow up for testing or procedures and or adherence to continuing prescribed treatments or therapies. These clients often have difficulty identifying accountability of providers regarding whom and which provider is responsible for what. Failure to transition properly often occurs because of communication breakdown.

Goals:

  • To promote the efficacy of coordination of care
  • Ensure continuity of care
  • Ensure appropriate information is communicated to multiple providers to ensure a safe transition.
  • Identification of barriers to care