How do you improve overall patient health and minimize costs? Keep the patient at the center of attention and allow physicians to focus on their clinical practice while providing them with a supportive network of best practices.
IntegraNet Health uses hospitalists and care coordinators to monitor the progress of our patients, interact with patients’ family members as needed and recommend needed steps for ongoing care.
Please use our interactive diagram below to learn more about each phase of IntegraNet Health’s care coordination process and read the example scenario of how patients, phyisicans and health plan providers benefit from this solution.
A care coordinator is then assigned to check on the patient’s wellbeing and determine if a medical home specialist is needed. If a medical home specialist is not needed, the care coordinator will continue to check in periodically by phone with the patient and will report back to the primary care physician. The patient feels good about the level of care being delivered, the physician is able to use his/her time efficiently and effectively, and the health plan provider incurs lower costs when patients receive the medical help they need without return visits to the hospital.
If a medical home specialist is needed, the care coordinator makes all the arrangements.
A medical home specialist is a home-based nurse or nurse practitioner who works closely with the assigned patient and the primary care physician. Within one week of hospital discharge, the medical home specialist begins visiting the patient to assess the home environment, perform a physical exam, review medication, educate the patient on needed care procedures and evaluate overall home care needs. HRA, care plan, HEDIS and 5 Star measures are communicated to the primary care physician by the medical home specialist, ensuring diligent care of the patient. A follow-up visit with the primary care physician is also recommended. Home visits continue until the medical home specialist and the primary care physician believe the patient is no longer in needed of such care.
The medical home specialist improves overall patient health by regularly monitoring patient progress, providing continuous feedback to the patient’s physician(s) and allowing the physician to devote more time to office patients. Both patients and health plan providers benefit from consistent patient monitoring, continuous communication with the physician(s) and fewer repeat visits to the doctor’s office. If you are interested in becoming part of the IntegraNet Health system as a physician, health plan or patient, please contact us for more details. Better medical care is just a call away.