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Continuum of Care    
Large hospitals, who face cost containment pressures from various sides, must continue to improve the efficiency with which they strive to provide quality care.  The target patients, some of whom are insured, largely interface with these urban hospitals through the Emergency Department (ED).  Providing non-urgent or ambulatory care in the ED is not only an indicator of sub-standard care, it also is financially inefficient as ED costs for minor, non-urgent clinical issues are 2 - 5 times higher than for a typical primary care office visit.
Our services are deeply grounded in the notion that "Everyone and Every Touch" is significant.  This key principle drives the development, delivery and assessment of the services we provide to patients and clients.  Our services are categorized across three dimensions:


We provide services in 3 areas:
  1. Analysis of inefficient and inequitable care - Community Care Coordination
  2. Evaluation of community based health improvement resources
  3. IT Solutions
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Analysis of Inefficient and Inequitable Care - Community Care Coordination

Our current focus is partnerships with large, urban hospitals to analyze selected, frequent ED users and first determine eligibility of care. Then further analysis determines candidates for providing access to a continuum of care, through Community Care Coordination (CCC), which reduces their ED visits, resulting admissions, and health disparities. Our unique model of care coordination is based on a world class model of preventative activities segmented across 3 areas:

  1. Primary Prevention - Efforts provided to individuals to prevent the onset of a targeted condition
  2. Secondary Prevention - Efforts that identify and treat asymptomatic persons who have already developed risk factors or pre-clinical disease, but the condition is not clinically apparent
  3. Tertiary Prevention - Efforts involving the care of individuals with established diseases, and prevent disease-related complications

Our partner Community Care Coordinators evaluate patients according to this holistic model of care. Our experience has consistently shown that this framework is necessary to effectively provide a continuum of care to our target population.

Evaluation of Community Based Health Improvement

Existing community based resources are essential in establishing a continuum of care and evaluation of these existing resources is necessary to establish partnerships and determine gaps. Proper evaluation must be periodic as new services emerge, others expire, and organizations shift. This service, while currently not stand alone offering, plays a critical role in building the continuum of care.

IT Solutions

Determining and tracking individual drivers of health across primary, secondary, and tertiary activities is a key offering. As we grow and expand, innovative IT-enabled solutions is an important part of tracking and reacting to patient health variables and drivers. Drivers of health outcomes can be influenced by a broad spectrum of variables across primary, secondary, and tertiary categories and several factors influence individual circumstance. Events ranging from a family member losing a job or being incarcerated to having to care for a sick parent can have a profound effect on individual health.

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