Care@Home is a collaborative in-home clinical model for your frail, high-risk and vulnerable patients.
Care@Home is designed to help high-risk patients who:
Have frequent, potentially avoidable hospitalizations
Have five or more chronic conditions and need help to get them under control
Visit the ER for non-emergency care after-hours or on weekends
Take many medications and find it hard to manage them all
Are frail and find it difficult to leave home for their care
Care@Home Approach
Medical and Behavioral Health Care
Team-based model
POD/Neighborhood structure
Interdisciplinary support (MD, NP, Dietitian, Pharmacist, Social Worker, Behavioral Health Specialist, RN Care Manager, Care Coordinator)
24/7 triage, in-home urgent visits when needed
Medication reconciliation
Comprehensive care plan
Patient Focused
Patient and Caregiver Education
Social determinants of Health
Single point of contact for member/family/caregiver
Caregiver assessment and training
Disease specific program training
Palliative Care
Psychosocial care & community resources
Transition to Home Hospice Care
Pain Medication management
Facilitate optimal health and independence
Clinical Collaboration
Transitions Care Management
Primary Care Partner
Work collaboratively with PCP and Specialists, does not replace
Video conferencing and other technology platforms for optimum communication
Diagnostic Testing
Conditions Managed/Treated In-Home
Heart failure
Hypertension
COPD and Asthma
Diabetes
Chronic Kidney Disease
Alzheimer’s/Dementia
Coronary Artery Disease
Cancer
Liver Disease
Rheumatoid Disease
Stroke
Urinary tract infections (UTIs)
Fever, colds, pneumonia, upper respiratory infections
Cuts, wounds, and rashes
Cellulitis and abscesses
Nausea, vomiting, and gastrointestinal issues
