Population Health

Population Health services offered in Goodyear, Tempe, Mesa and Sun City, AZ

It is no surprise that population health is gaining popularity over the recent years. Managing disease burden, improving access to care, enhancing patient experience, and reducing per capita cost are primary targets. We accomplish these goals through various programs designed as an extension of payers. By leveraging available data, patients will be followed and positioned into one or more of our programs discussed below.

Transitional Care Management

The transition of care from acute or subacute level to home is not a hurdle anymore. Our patients obtain Timely follow-up, support, coordination, and a face-to-face visit post their discharge. For 30 days we do telephonic case management weekly to ensure stability and safety.

Disease Management

Patients who develop one or more chronic diseases will benefit from shared time with our professional nurses to be educated and involved in their treatment plans. We ensure comprehensive medication management, empowerment in disease treatment, and feedback from involved providers.

Medicare Risk Adjustment

Accurate HCC capture is necessary to obtain the proper health status of beneficiaries. Our team seeks to investigate previous encounters, charts and claims data to assess disease burden accurately. We also verify obtained information with a face-to-face visit with patients.

Palliative Care

Patients with a terminal illness will be enrolled in our palliative care program. They will be followed biweekly by a provider for symptom management and collaboration with families to optimize care and end-of-life planning/hospice.

Emergency department

All members admitted to the ER are eligible for this service. We facilitate direct ER to SNF admission for appropriate diagnosis. We also coordinate Home health needs and acute provider visits after Discharge.