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Population Health

Care Coordination

The care coordination program is a safeguard that is designed to keep our patients healthy. Our program is staffed with physicians, physician assistants, nurse practitioners, nurses, social workers and medical assistants.

Within our program we have a transitional care management and chronic care management team that works closely with our community physicians to monitor patient traffic, zeroing in on admissions, discharges and ER visits with our chronic and high-risk patient population. This allows us to capture and prevent the progression of ambulatory sensitive and chronic conditions.

Care coordination is the keystone to our organization, allowing us to keep our patients healthy while fostering an intimate patient relationship and maintaining a keen eye to quality and utilization.

Home Assessment

The home health assessment program is an added benefit for patients under our CAIPA umbrella, with the intention to close the gaps in care, but not replace the care provided by their primary care physician. We provide an annual medical assessment to qualified patients to monitor their health status. This service is furnished by licensed medical providers also known as Advance Practice Providers (APP), such as Physician Assistants (PA) and Nurse Practitioners (NP).

The assessment encompasses a broad range of medical, social and psychological evaluations, which includes but not limited to the optimization of medical diagnoses, medication reconciliation, depression and anxiety screening, cognitive assessment, activities of daily living (ADLS) assessment, nutritional survey and social assessment.

Any unaddressed needs that are identified through our assessments are directed to the appropriate resources, such as case managers or the patient’s primary care physician. The overarching objective of the program is to identify missed gaps, monitor chronic illnesses and improve the accuracy of the patient’s diagnosis. Our service, in addition to our case management further assists our PCPs effort in maintaining and improving the health of our patients.

Individualized Physician Management Services

Changes within the healthcare landscape have created layers of administrative hurdles for our physicians. Our Individualized Physician Management Services is designed to unchain our doctors from all the administrative burdens, allowing our doctors to be doctors.

As large healthcare systems continue to jeopardize the existence of solo and small private practices, it is within our core DNA to maintain the independence of our physicians. We provide a spectrum of services such as, but not limited to, practice management, ancillary clinical support, human resources support, information technology support, billing and coding, and maintenance.

Creating an environment that is sleek, innovative and modern, in addition to our added services, allows us to remain competitive to attract healthcare professionals to care for the people in their community.