- Utilize our specialized care management software to call Medicare patients with 2 or more chronic conditions (Diabetes, CHF, Chronic Pain, COPD, etc.) on a monthly basis
- Build and maintain rapport with patients to help coach them to improved health through SMART goals and education on self-management strategies
- Implement and improve the Plan of Care by updating medications, appointments due, biometrics, symptoms, and interventions made
- Connect the patient with community resources as needed, including transportation, personal care needs, prescription/DME assistance, social services, etc.
- Conduct Transitional Care Management activities to high risk patients discharged from the hospital and the ER to reduce unnecessary readmissions.
- Close care gaps by encouraging and assisting with preventive care measures, i.e. annual well visits, vaccines, cancer screens, follow-up/specialist appointments, etc.