• Typical Healthcare Experience vs Clinically Integrated Network

Our innovative care management strategy centers on the primary care component of health care. It is critical that primary care providers are connected seamlessly with all network providers, each with access to the tools and resources they need to provide the right care, at the right time, in the right place.

This technological connection allows providers to make well-informed clinical decisions. We touch every aspect of our patients’ health by maximizing their experience with providers at all levels of care, and focusing attention on optimizing health, versus illness and disease.

Our strategy has three primary components:

Multidisciplinary Team: Alongside your provider, our local multidisciplinary clinical team members engage, educate and assist your patients using population health management strategies. Team experts include:

  • Registered Nurse Ambulatory Care Coordinators
    • Providing additional needed attention to high risk patients with chronic illnesses
  • Social Worker Ambulatory Care Coordinators
    • Supporting patients’ needs such as support for housing, transportation or medications
  • Ambulatory Care Pharmacist
    • Providing a wide-range of services including investigating lower cost options to increase patient medication adherence
  • Ambulatory Care Coordination Assistants
    • Facilitating care coordination for patients discharged from hospital
  • Care Coordination Assistants
    • Scheduling patients for preventative screenings

Population Health Management: Our proactive application of strategies and interventions to defined groups of individuals across the continuum of care improves the health of those individuals at the lowest necessary cost.

  • Improve Access to Care
  • Assist in the coordination of patient transfers between environments of care
  • Manage 90-day episodes of care
  • Reduce hospital readmission rates
  • Collaborate with the provider practice to identify and schedule needed prevention screenings
  • Care Management Process
  • Care Management Approach includes RN Quality Care Coordinator, Clinical Pharmacist, SW Ambulatory Care Coordinator and Certified Medical Assistant