The goal of our Care Transition Intervention Program is to ensure a smooth transition of the patient from hospital to home, reduce avoidable rehospitalizations, and most importantly offer the support of nurse practitioners, nurses, and social workers to serve as Care Transition Coaches to patients and their primary caregivers who may lack the skills, tools and confidence to coordinate all the services they need following a hospital discharge. The Care Transition Intervention plan for a patient following a hospital discharge is not the same for everyone. Each patient’s need are evaluated separately and plan of care is tailored made to meet their specific needs.
Vital Care Management
The Vital Care Management (VCM) program is specifically designed for coordination and connectivity between interdisciplinary care teams of physicians, nurses, social workers, pharmacist, and support staff, offering patients with chronic medical conditions a resources to meet the daily challenge of living with a chronic medical condition. Working closely with the patients primary care and attending specialist physicians, our clinical team provides direct care to patient following approved disease management clinical guidelines. Our patient centric approach is designed to equip patients and their caregivers with the knowledge to recognize the signs and symptoms of disease complication and encourage them to play an active role in managing their chronic disease and improve clinical outcomes.
Quality Measures Management
Assigned patients enrolled in Medicare or Medicaid managed care insurance plans are offered annual wellness exams. These visits allow our clinicians to assess the patient to determine their health status and support the efforts of the patients primary care physician to achieve care delivery performance measures ensuring that each eligible patient receives the health and preventative services available to them.