Dedicated patient navigation teams help ensure patients are seen by the right provider. We have more than 200 employees in primary care practices and central call centers to ensure appropriate care transitions occur in a timely manner. This also ensures clinical information is transmitted in an efficient manner.

These programs work closely with hospital care transition teams and care management teams to ensure patient needs are met, and to support physicians and their care teams.

Individual patients are not only members of multiple populations, but move among different cohorts as circumstances change. Because of this, we need both the close-up view of individuals and the wide-angle perspective of entire populations to see and manage these cohorts clearly and effectively. This provides added services to patients with highly complex conditions, chronic diagnoses, multiple comorbidities and those that may need help adhering to treatments.

Our Care Coordination team includes skilled care managers, social workers, and pharmacists, who help identify patients with complex and chronic conditions. These experts collaborate to fill gaps between primary care services and patients’ care, offering resources related to coordination among multiple doctors, access to resources, long-term support, and remote monitoring.

Post-acute care is a major factor in our costs and outcomes which is why we’ve established processes to mitigate/reduce the total cost of care for these patients. 

We offer a care model with providers selected to deliver care that even includes robust home health care services. This enables us to deliver the right level of care for the right reasons to patients both in and out of the hospital.