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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