Complex Care Management:
An ongoing program to support high-cost, high-risk patients at home to reduce
overall medical expenditure
In summary, the Complex Care Management program includes:
- Monthly in-home assessment with a registered nurse
- In-home assessment with a pharmacist, as needed
- Creation of a multi-month care plan reviewed with patient’s primary care physician
- Telephonic health coaching from registered nurse and support from a personal care coordinator
- Custom reports for patient and physicians
- In-home telemonitoring of key vital signs as needed to monitor patient status
- Patient education on advanced care planning
- Caregiver support and care coordination as appropriate