We don’t wait for patients to call us or for crises to happen. We actively reach out and take a proactive approach to executing your population health strategy. That means we identify at-risk individuals and engage them before they slip through the cracks. For example, if a patient hasn’t been seen in a while and has uncontrolled hypertension, we reach out to offer our support and get them back on track. If a patient starts to show a pattern of deteriorating readings or missed meds, we intervene immediately. This anticipatory stance prevents problems rather than just reacting to them.

Our services are designed to integrate seamlessly with your practice and EHR – we become a “virtual extension” of your team, not an adjunct service that disrupts things. We have expertise in working with or integrating with all major EHR systems. We log our activities, update patient charts, and communicate with your staff in real time. This means no duplication of work, no siloed notes that the physician can’t see – everything is connected. We can also integrate with existing programs you have; for instance, if you already have an existing care team, we can escalate to them and help them operate at the top of their license.

We know healthcare organizations are busy and don’t have time for long ramp-ups. Our approach is turnkey – we have the playbooks, trained staff, technology platform, and process flows ready. When you bring us on, we rapidly deploy our services with minimal lift on your end. For example, we have templated patient enrollment scripts, tried-and-true engagement workflows, and a predetermined cadence for communications and reporting. You don’t have to invent anything; we bring a fully functional solution.

Our approach combines the right team with the right services and the right strategy. We hire experienced nurses, care coordinators, and support staff who are passionate and top-notch performers. Then, we place them into a system of disciplined processes – everything from how we make calls, how we document, to how we escalate issues is governed by protocols refined over years. This consistency means high reliability in execution. Many programs fail due to variability (one nurse does it one way, another differently). Our integrated approach means you get consistent, reproducible results – which sets us apart.

We leverage technology like remote monitoring devices, data analytics, and automation for efficiency –  technology-enabled daily nurse care coordination is one way we strike the critical balance. However, we ensure the human touch remains at the core. Our approach isn’t to give patients an app and hope for the best; it’s to use apps/devices to supplement and empower our team. For instance, our platform might auto-alert a nurse to a concerning trend, but then a human decision and personal intervention follows. Clients often remark that we’ve found the right mix of tech and touch: enough automation to scale and gather data, but not so much that it loses personalization.

Our approach looks at the patient holistically. We don’t say “not our scope” if a patient raises an issue outside narrow definitions – we find a way to help or connect them to help. We also involve the patient’s own providers closely. We operate as a seamless, extended member of your care team, meaning we work with the physicians, updating them, aligning with their care plans, and not creating any friction. That integrated, collaborative spirit is fundamental to our approach – everyone (patient, us, provider, even family) is on the same team.

Our approach is very aligned with value-based care principles – focusing on outcomes, preventative care, and cost-effectiveness. We’re constantly asking: does this intervention bring value? We prioritize actions that improve quality or reduce cost or ideally both. For example, we’ll focus more effort on patients who stand to benefit most (risk stratification) to maximize the value of each contact. This mindset ensures that what we do translates into real improvements in metrics that matter for value-based contracts – a huge plus for organizations transitioning from volume to value.