Integrated on-site care management for acute ventilator-dependent patients that have been historically difficult to manage due to a combination of factors:

1.) These are complex patients.
2.) Difficulty for the health plan nurse care manager to access the hospital ICU and treating physicians.
3.) These complex cases require a respiratory and pulmonary expertise which is in addition to the traditional health plan care management.

On-site Care Managers in 15 U.S. markets with access to 400+ acute care facilities:

• Criteria for intervention: 72-96 hours from intubation.
• Unique scalable national program treating adults & pediatrics patients.
• On-site data collection and interdisciplinary team approach while coordinating discharge planning and improving the patient and family experience.

• Improving the quality of care delivered to patients while impacting readmission rates, HEDIS scores, and STARS rating for Health Plans.
• 30-day readmission rates below 6% for Medicare and Commercial Health Plans over a 10-year period which is well below the national average.
• On-site data collection and interdisciplinary team approach while coordinating discharge planning and improving the patient and family experience.

• Significantly reduces inpatient and other healthcare expenses related to catastrophic hospital charges.
• Coordinate LTCH, SNF or Home placement throughout the continuum of care.
• Improve overall quality measures, and reduce hospital 30 day readmissions.
• Educating families as to palliative care and hospice.
• High percent of patients enrolled in hospice which is historically not well understood or accepted by families.

Integrated On-Site Care Management for acute non-ventilator patients that are medically complex:

1.)  Are non-vent, complex patients, typically in the ICU or step-down unit with 2 or more comorbidities.
2.) Difficulty for the Health plan nurse care manager to access the hospital facility and treating physicians.
3.) Review of these complex cases requires on-site review of the case and coordination with the treating physicians and health plan.

On-site SOS Care Managers in 15 US Markets with access to more than 400 acute care facilities

• Criteria for intervention: Critically ill patients, with an acute hospital ALOS typically in the “outlier status” with 2 or more co-morbidities.
• Typically these patients are in the top 5% requiring LTCH.
• On-site data collection and interdisciplinary team approach while coordinating discharge planning and improving the patient and family experience.

• Improving the quality of care delivered to patients while impacting readmission rates, HEDIS scores, and STARS rating for Health Plans.
• 30 day readmission rates below national Medicare average, and evaluation for post-acute Readmission Reductions Program “RRS”.
  • Engage the family and physicians in the appropriate use of hospice.

• Most common diagnosis include:

  • S/P Mechanical Ventilation with tracheostomy or other pulmonary needs including FIO2 30% or greater and are at risk for re-vent.
  • Sepsis, CHF, COPD, or requiring complex Wound Care.
  • DM with infection, ARF, ESRD, or Cardiomyopathy.
  • All other “CCI,” or Chronically Critically ill patients.

  Quarterly Reporting Metrics include:

  • Readmission trends.
  • ALOS and Utilization Data.
  • Hospice Enrollment Percent.
  • LTCH Utilization Data.