INSPINARY CareTeam 365 is a direct communication service partner to hospitals, Health Plans, Physician Practices. We offer patient monitoring, daily patient assessment and medication management via scheduled daily phone consultations to the patients. In today's value-based healthcare environment, where revenues depend on fast and effective identification and engagement of at-risk patients Inspinary Care Team 365 is the perfect solution.
In order to close the gaps in care, monitor patients' status and conduct targeted outreach without any sophisticated technology except a simple phone consultation. This is especially helpful for patients that are not techno savvy and majority have no smart phones either. Inspinary CareTeam 365 partners with our clients to offer direct patient communication 7 days a week 365 days of the year. All that a patient requires is a regular landline or a cell phone where our dedicated RN care coordinators, Nurse case managers and Pharmacist can reach out and perform phone assessments, guide, motivate, monitor the patient and identify potential health risks and report the findings to Care providers / Physicians' offices for timely intervention to avoid Emergency room visits and hospital readmissions.
Our offerings include the following:
- High Risk Population Care Management
- Post-Discharge Outreach and Management / Transitional Care
- Preventive Care Program for low risk population management
HIGH RISK POPULATION CARE MANAGEMENT
Identifying at-risk patients and gaps in care
- A CareTeam365 RN Case Manager is assigned to certain high risk patients to work with. The RN Case Manager engages with a pool of patients that have higher than average resource consumption and emergency department use, as well as an increased likelihood to be admitted or readmitted to the hospital.
- RN Case managers and RN Care Coordinators connect with patients to understand and resolve each individual's unique barriers to care and then follow up with the patient regularly via phone consultations. If needed a Nutritionist, Health Coach are also involved to ensure the patient is proactively engaged in self-care.
- Any significant information captured during patient interactions is shared with the Care providers.
- Moving the high-risk category patients to becoming self-sufficient in their care and improve patient engagement in self-care and disease management to reduce hospitalizations, avoidable emergency room visits and avoidable readmissions
- Our assigned CareTeam365 Pharmacist will ensure that individuals understand their medication list, reasons for the meds and outcomes of non adherence along with dosage and usage reminders.
Preventive Care Program
LOW RISK POPULATION CARE MANAGEMENT
In order to avoid hospital admissions it is essential to first collaborate with patients to prevent the unnecessary admissions. Waiting until a patient is admitted to realize he or she is high risk for readmission already puts care providers behind the curve
- A major goal of Inspinary CareTeam 365 is to engage individuals to ensure they are fully involved in their health and wellbeing by offering preventive care
- Each individual is assigned a Nurse Care Coordinator who maintains regular contact with individuals identified as low-risk to motivate them to participate in preventive screenings, check-ups and maintaining a healthy status.
- Inspinary CareTeam 365 stays connected and follows through with Physician appointments and ensures further follow up after the Physician appointment is completed
- Identifying risk and ensuring timely proactive discovery of risk factors, alerting to notify Physician for further interventions during weekly follow up call with low risk population.
POST DISCHARGE CARE MANAGEMENT / Transitional Care program
Hospital Post-Discharge Management / Post-discharge outreach
- When patients leave the hospital or an emergency department, the effectiveness of follow-up becomes crucial to their recovery.
- CareTeam365 offers daily follow up phone Consultation to ensure proactive post-discharge assessments, alerts, notifications and reports it to Physicians ensuring close monitoring for high-risk patients, and prompt attention to all patients who require additional assistance.
- Assigned CareTeam365 Pharmacist offers medication-related expertise to give best education to discharge patients, embeding a "Teach-back Process" to validate patient and/or caregiver comprehension of the medication management related to information provided
- Pharmacist reinforces Discharge medication dosage and usage instructions, provides patient education, will also check medication reconciliation, and will follow up with the patient by weekly phone interaction.
- CareTeam 365 will monitor each Hospital discharged patient daily by assigned Nurse Care Coordinator who connects with patient via phone consultation, for info on Vital signs, Weight, medication compliance, blood sugar monitoring, exercise, diet, and to identify any stressors at home.
- The Nurse Care Coordinator will provide patient information of any critical deviations to care providers giving them a sense of how their patients are faring at home.
- Improve patient compliance in addition to reminders about follow up labs or physician visits. Reinforce all doctor-to-patient communication during calls
Transitional care program:
- Nurse Care Coordinators offers regular phone consultations to track Progress – Pre-appointment planning and facilitating Medical appointments.