Care Management Services

Chronic Care Management

The PrimeCare Care Teams have trained Nurses available by phone 24/7/365 to assist patients if they have health questions or concerns. The Care Team can access patient’s medical record and has open communication with physicians to ensure a continuity of care. The Care Team’s role is to assess and monitor patient’s medical condition by engaging with you and to provide education. Care Team check-ins help fill gaps in care and give patients an extra layer of enhanced chronic care management and care coordination. Patients struggling with chronic diseases, such as congestive heart failure, diabetes, AFib, hypertension, and COPD, have a better quality of life and control of their chronic illness with Care Team services. A recent case study determined Care Team Services reduced patients’ overall healthcare costs. (Source

• Coordination
• Patient Education
• Risk Assessment
• Intervention

• Referral Assistance
• Transitions of Care
• Medication Adherence
• Monitoring for Medical Compliance

Transitional Care Management

The practice of transitional care management after stays at Hospital, SNF, Rehab. & Behavioral aims to identify and overcome barriers to successful transitions and prevent gaps in care. The goal is to improve the patient experience while saving the health care cost of readmission.

• Start Discharge at the Time of Admission
• Ensure Medication, Education Access, Reconciliation & Adherence
• Arrange Follow-up Appointments with PCP
• Arrange Home Healthcare

Remote Patient Monitoring

There are many benefits to Remote Patient Monitoring. Ongoing vital readings help you and your provider ensure your care plan is working for you and provides early detection of health deterioration. Medical devices are FDA approved. Patients who participate in an RPM program have shown to have less hospital and ER admissions and have improved health after 12-18 months. (Source

• Blood Pressure • Heart Rate • Blood Oxygen • Weight • Glucose

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