What our clinicians do.
We treat members at home.
We look at home readings every day and hear about ER visits, admissions and missed refills. Members reach a clinician day or night. Our own clinicians titrate heart failure and COPD medicines to treatment doses, treat flare-ups early with rescue medicines and diuretic changes, and manage what travels with them: diabetes, kidney disease and sleep apnea. Members without a heart or lung specialist get ours.
We do the little things that get forgotten.
After a discharge we call, reconcile the medicines, and confirm that oxygen and equipment are in place and follow-up is booked. We arrange labs, imaging, referrals and refills, and see that they happen. Caregivers are part of the plan. Each member's doctors get the care plan at enrollment, a note at every medication change, ER visit, admission and discharge, and a monthly summary.
We keep members engaged.
The same four to six clinicians stay with each high-risk member, with about 30 clinical contacts a year. A third of our patients have no home internet and a quarter have never used a smartphone, so every device arrives with cellular service built in and is set up by phone. Respiratory therapists teach each member their condition and their inhalers, and we help them quit smoking. Support groups and group exercise sessions give many homebound members their main contact with other people.
