Nurse laughing with patient.

DEDICATED CARE THAT CAN HELP WITH YOUR MOST DIFFICULT CASES

Our Chronic Condition Programs focus on a health plan's top 5% of health care utilizers and either extend physicians' reach or assume the role of primary doctor for members. Treating and visiting in the home allows us to identify barriers and develop a more personalized care plan to address their needs.

Complex Care Program (CCP) Collaboration

We work with you to identify members that could be positively impacted by CCP. Once identified, we work with primary care physicians (PCP) to determine if the member is truly a good candidate. The PCP must agree and provide final authorization for the member to enroll in CCP. Once the member is enrolled, our nurse practitioner will work with the PCP to determine what care can occur in the home.

While in the home, our nurse practitioner will gain some insight into possible health and social issues that the member might be facing. These observations will be shared with the PCP in order to collaboratively develop a revised care plan, if needed.

Our in-home care program can be very useful for these members. However, we recognize and respect that the PCP is still fully engaged and accountable for all care decisions and we will transition the member back to their PCP full time if and when appropriate.

Chronic Care Management (CCM) Program Collaboration

Alegis Care will work with you and the original PCP to better understand the historical and recent treatment and care. Once we confirm that our health professionals will manage the care of the member, the following steps will generally occur:

  • Our doctor will conduct a full physical exam and review medications that the member currently takes
  • Based on results of the exam, the doctor will develop a care plan and share with the member and pertinent caregivers
  • Our doctor and team will visit the member in their home on routine basis (usually monthly).  Frequency of visits will be determined by the personal care need.
Alegis Care Team

The team that will care for your members is led by a board-certified physician who is supported by in-home nurse practitioners, telephonic registered nurses and a central 24-hour customer service hotline.

Our doctors and nurses live in the areas that they work. As such, they have developed relationships with other health resources that may be needed for care such as:

  • Specialists
  • Diagnostic labs
  • Home health agencies
  • Hospice
  • Social agencies
Members Who Qualify for Our Chronic Condition Programs

Members who benefit most generally have more than 2 hospitalizations and/or more than 3 emergency room visits in the year prior to referral, and are chronically ill with multiple uncontrolled comorbidities; including:

  • Heart Failure (CHF)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Asthma
  • Chronic Kidney Disease
  • Diabetes Mellitus
  • Coronary Artery Disease
  • Dementia

The members who benefit from our CCM program are also either homebound or lack access to care.