Transition of Care
Case Managers are healthcare professionals- RN who serve as a point of contact for an individual recently admitted.
This person seeks out and coordinates resources, monitors progress, and communicates with the Medicare Fee for Service Beneficiary, family, and other healthcare professionals. Responsible for the concurrent review and discharge planning process of members. Coordinates all necessary healthcare services pre and post hospitalization to avoid preventable re-admissions.
Ensure that all eligible beneficiaries with identified healthcare needs and/or requiring ongoing case management, will be evaluated and afforded the opportunity to receive the necessary medical treatment to maintain an optimal state of health and well-being.
Incorporate a collaborative process to access, plan, implement, coordinate, monitor and evaluate options and services to meet the beneficiary’s health needs using communication and available resources to promote quality with cost effective desired health outcomes.
Focus on disease specific programs that have been implemented to meet healthcare needs of the plan’s membership.
Develop programs that include prevention, education and physician directed management of targeted chronic diseases, including Hypertension, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure and Depression.
Operates the Preventive Medicine program and focus on high risk patients to avoid preventable diseases and complications.
The program consists of preventative, diagnostic and therapeutic services for types of patients that are considered at risk. The program included but not limited to promote immunization, balanced nutrition; and colorectal and breast cancer screening.
Social Care Management
Social Workers assist and educate our beneficiaries on available community resources, state/local social programs including but not limited to housing, food, transportation and pharmacy resources.
UniPhy ACO will implement during the first quarter of 2016 all Next Generation ACO Benefits Enhancements which include: Telehealth, Three-Day Skilled Nursing Facility Rule Waiver and Post Discharge Home Visits.
Telehealth services allow you to receive some health care services using real-time communication between you and your primary care doctor or specialist.View List
3-Day Skilled Nursing Facility (SNF) Rule Waive
Under current Medicare law, Medicare only covers care in a SNF if a patient has a prior three-day inpatient hospital stay. This new feature may allow you to get Medicare covered SNF services at a participating SNF without a mandatory three-day inpatient hospital stay.View List
Post-Discharge Home Visits
UniPhy ACO is expanding its post-discharge service to provide more comprehensive follow-up care at home after discharge from a hospital to help with the sometimes challenging transition between the hospital and home.View List
Get in Touch
If you have any questions, comments or just to want to reach out, please contact us.contact