Integrated Clinical Model of Care

Primary Care

Primary Care SNF

• Medical Directorship
• Clinical team includes an APP and a physician with MA support
• High facility visit frequency to deliver hospital discharge/new admission care and visit plan, regular chronic care visits with acute, pain, and other ancillary care provided as medically necessary

Primary Care ALF

• Clinical team includes an APP and a physician with MA support
• Regularly scheduled frequent in-person facility visits to attend to chronic care needs with each consented patient seen a minimum of once every 30-days and more frequently when medically necessary

Behavioral Health

Psychiatric Med Management

• Clinical team is made up of a psychiatric specialty trained NP or PA and supported by a Psychiatrist
• Regularly scheduled frequent in-person facility visits to attend to behavioral health needs with each consented patient seen a minimum of once every 30-days and more frequently when medically necessary
• Services include full evaluation of mental health concerns and cognitive assessments

Psychotherapy

• Non- pharmacological care provided by professional therapists and psychologists
• Visit frequency determined by individual patient medical necessity

Care Coordination and Chronic Care Management

• Team of dedicated care coordinators provides support to all clinicians in the field
• Providers collaborate with one another, facility staff, and patients’ families to ensure a seamless care journey for patients
• Chronic Care Management team and care coordinators ensure care plans are properly integrated and services are delivered and documented