The many complex needs of high-risk patients is often underserved in today’s health care delivery system. By combining high-risk patients with our comprehensive and chronic care management support, Care Solutions Group (CSG) effectively delivers care in the community, dramatically improving quality and reducing costs.
CSG’s extensive experience in care management includes contractual work with HealthPlus of Michigan’s and Health Alliance Plan’s Medicare and Dual Special Purpose Needs populations. CSG’s Registered Nurses were instrumental in improving program outreach to nearly 70% compared with the plan’s in-house success rate of 55%. This improved connectivity with plan members enhanced compliance and improved HEDIS scores.
Combining the Chronic Care Management Program with Remote Patient Monitoring technologies allows for real-time monitoring of a patient’s clinical condition and provides for more timely interventions. The RPM Program educates patients on the effective utilization of these technologies designed to monitor cardiac conditions, INR, blood pressure, blood sugar, saturation level, weight and temperature.
CSG focuses on enhancing the care for these high-risk and costly patients by utilizing the following solutions:
- Comprehensive in-home assessment, diagnosis and treatment; assessment includes clinical, psychosocial, environmental, family/social support and medication review/reconciliation.
- Development of customized care plan that includes medical, social and behavioral needs and is coordinated with the PCP.
- Coordination of care with PCP, specialists and community-based providers.
- Follow-up nursing and physician visits to patient’s home for ongoing and urgent patient needs.
- Respond to urgent needs with providers on-call 24/7/365.
- Ongoing follow-up with a dedicated RN Care Manager assigned to each patient.
- Connected Electronic Medical Record to access the care plan, notes and interventions.
To address needs and stabilize high-risk patients, CSG will dispatch a physician, physician’s assistant or nurse experienced in managing the multiple needs of these patients. To support ongoing as well as urgent clinical needs, CSG’s care management is further enhanced by its telephonic support designed to educate, support and assist with care coordination and compliance.
Through our patient-centered model of care and ongoing interventions, CSG improves care and lowers costs through:
- Emphasizing self-management
- Recognizing triggers
- Aligning treatment goals
- Emphasizing medication management / reconciliation
- Coordinating care with PCP and ancillary providers
Our comprehensive, high-touch program is designed to reduce avoidable readmissions, preventable hospitalizations and emergency room visits.