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Value-Based Care Keeping your patients healthy at home.

Offering value-based healthcare services designed to maintain the complex care required by your patients.

Why value-based care?

Because we realize a patient’s disease state is only one factor in their quality of life.  Quality patient care is not one-size fits all – our teams engage in high-touch interventions, giving us a 360° view of the complexities surrounding each patient’s disease state.  

Interdisciplinary team

Our interdisciplinary teams are comprised of community health workers, nurses, respiratory therapists, pharmacists and health coaches. Together, they work to transition patients from the hospital to their homes and provide support and education for managing complex disease states as they identify and remove barriers to our patients’ health.  

We partner with physicians and health systems to keep your patients healthy at home. Our value-based care approach improves the lives of patients while reducing hospital admission rates and saving healthcare dollars. 

Transition of care: from hospital to home

We use an advanced discharge planning methodology to transition patients from in-hospital care to their homes.  

Our Clinical Transition Liaisons will meet patients in the hospital to train them on what to expect as they transition from the hospital to their home. Our team will explain any maintenance required and will ensure each patient understands how to perform their prescribed therapy.  

Our teams will help coordinate with the patient’s home health organization to ensure there are no gaps in care. From there, our teams will evaluate your patient’s home and lifestyle to remove barriers hindering their path to better health. 

Healthy at Home® - a comprehensive value-based care program

Our advanced discharge planning methodology and value-based care approach improves the lives of your patients while reducing hospital admission rates and saving healthcare dollars. 

In-home services are necessary for diagnostic categories such as

  • Congestive Heart Failure
  • Chronic Obstructive Pulmonary Disease
  • Pneumonia
  • Acute Myocardial Infarctions

Our program includes:

  • Pre- and post-discharge education from a clinician
  • Successful transition from hospital to home
  • Medication management
  • Proactive patient engagement and education
  • Care coordination within the home setting
  • Care coordination within the home setting
  • Early intervention to reduce future ER visits and hospital readmissions
  • Community health worker involvement
  • Pharmacy and nursing as needed
  • Outcome reporting

The Community Health Worker partnered with a community pharmacy has been a substantial resource assisting patients in my recent experience. They have acted as liaisons and educators resulting in enhanced medication compliance, knowledge regarding disease processes and subsequently decreasing hospitalizations. I will continue to utilize the program for select patients who require specific assistance as I know it helps to facilitate optimal patient outcomes.

Meghan Bassett, Tallahassee Pulmonary Clinic