Our Clinical Model

Clinical Population Management model
• Interview patient
• Identify medication discrepancies
• Contact last health care setting to clarify medication history
• Solve drug-related problems
• Obtain medication allergy information
• Document revised medication list on electronic medical record (EMR) system
• Post-Discharge MTM (medication therapy management)
• Clarify medications during transition
• Ensure appropriate use
• Identify drug related problems
• Provide complete medication record
• Create medication action plan
• List intervention to communicate with patient and provider
• Remind patients of other pertinent information
• Focused Interventions
• Ensure patient Adherence
• Medication Education
• Provide further recommendations
• Reduce 30-day readmission rates
• Reduce adverse drug events within 30 days of discharge
• Eliminate medication discrepancies
• Improve patient adherence
• Improve understanding of medication therapy
• Create care plan based on physician notes
• Plan readily available on portal for patient and physician review.
• Engage in twenty (20) minutes or more of non face to face interaction per patient every 30 days
• Provide patients access to CCM services 24/7- timely response to patient’s chronic care needs
• Provide Care Management for Chronic Conditions

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• Ensure continuity of care with a designated provider or health care team allowing for successive appointments with them
• Create a Patient-Centered Care Plan document that is a comprehensive plan of care for all health issues
• Manage care transitions among health care providers
• Coordinate with home and community-based clinical service providers
• Enhance patient-physician communication through use of secure messaging, internet or other non face-to-face methods
• Provide Coumadin dosage management services
• Help Physicians Off load all dosing work related to Coumadin management with a collaborative practice agreement
• Ensure weekly quality testing for PT/INR
• Provide training for PT/INR
• Provide Diabetes education for all diabetic patients
• Provide remote monitoring for Glucose, blood pressure, temperature, weight
• Offer support of clinical staff to physicians to support timely completion of “Annual wellness visits”
• COMING SOON – Provide equipment and technology related for tele-health/ virtual doctor visit