Our Continuity Services are designed for patients who are chronically homebound, mobility-challenged, unlikely to access ambulatory care services, and prone to high-cost inpatient utilization if not managed with ongoing, preemptive care. This “hidden under-served” patient is typically a high-risk, frail elderly, and disabled population, with multiple co-morbidities, frequent development of new medical problems, a greater possibility for costly inpatient services, and requiring a complex plan of treatment. This population is managed by face to face clinician visits; 24/7 on-call coverage; case management services and through communication and collaboration with all stakeholders.
Our goal is to provide regular access to care/ continuity of care, and function where needed as a “surrogate PCP”. Goals of care are to avoid unnecessary ER visits, hospitalizations, align patient expectations with prognosis, and optimize quality of life. We also provide ongoing management of patients enrolled in Palliative care and hospice programs.