- Welcome patients into continuous care program(s) and review benefits and services included
- Educate patients on the frequency and use of their assigned in-home monitoring devices
- Create a personalized, comprehensive care plan with the patient via phone or video visits
- Identify and address any barriers to patient success
- Provide specific education and coaching on patients' chronic conditions
- Connect with the patient frequently to review readings and a monthly update of their plan of care
- Serve as the patient's first contact for all non-emergent needs (example - medication refills, scheduling, appointment reminders, etc.)
- Anticipate patients' needs and bridge any gaps in care
- Assist patients in the navigation of their healthcare (example - assisting patients with scheduling appointments, coordinating with specialists, and ensuring preventative screenings are completed, etc.)
- Review and evaluate in-home device readings in real time, during normal business hours
- Follow established protocols for identifying, communicating and documenting device trends and any associated symptoms in the patient's medical record
- Escalate concerning readings and/or symptoms to the provider following a communication protocol established by the provider
- Establish a meaningful rapport that builds trust, open communication, and motivation to make a positive change in the patient's health
- Collaborate with virtual team members and in-office staff to ensure patient's needs are being met