ALISO VIEJO, Calif., April 17, 2018 – ConcertoHealth, the leading full-risk provider of specialized primary care and supporting clinical services for vulnerable, frail and elderly patients, announced today it is expanding its field-based care model in Michigan and Washington, to provide more support to health plans and their networks of primary care providers (PCPs) in caring for their highest-risk patients.
The expansion reflects the success of the ConcertoHealth care model, which dedicates field-based care teams and “wraparound” support services to health plans’ PCPs. Rather than replace or compete with the PCPs, ConcertoHealth supports their performance with an array of clinical resources, including social workers, care managers, pharmacists, clinicians, and nurses, to care for patients in any care setting, when they are most in need. To facilitate effective collaboration with PCPs, ConcertoHealth utilizes a proprietary population health analytics platform, Patient3D, which provides PCPs with a 360-degree view of each patient’s status and care needs.
“Health plans and their PCPs have now seen first-hand how our field-based care teams can support and extend the care they provide to their most medically and socially complex patients,” said Christopher Dodd, M.D., M.S., chief care transformation officer for ConcertoHealth. “By expanding our multidisciplinary field teams, we are transforming health care delivery, supporting PCPs to provide patients with the right care, at the right place, at the right time.”
ConcertoHealth care managers work in collaboration with PCPs and other care team members, integrating clinical and social services to ensure the best possible healthcare outcomes. ConcertoHealth deploys its field-based care teams to visit patients at the most risk for hospital admissions, and by serving patients in post-acute settings including group homes, assisted living facilities and skilled nursing facilities. Outreach also includes visits to patients who may not be regularly visiting their PCPs, and patients who are frequent visitors to emergency departments.
“Through our team-based approach, these patients have a single clinical champion to manage transitions-of-care, and design care and treatment plans that are tailored to their unique needs, ultimately helping to prevent avoidable hospitalizations and readmissions,” Dr. Dodd said. “Our care teams partner with PCPs and other care providers to assure that patients receive evidence-based, preventive care to stabilize their chronic conditions. We stand shoulder-to-shoulder with patients to implement care plans that maximize their health and quality of life.”
“For the patients who are unengaged or unwilling to engage, our care team meets them in any setting, be it in the emergency department, an assisted living facility, or even under the bridge. Building trust with our patients is the first and most important thing we do,” Dr. Dodd said.
Field-based care teams and care managers are already in place in Michigan and Washington, and ConcertoHealth is in the process of expanding its team in Southwestern Michigan. This expansion is part of a multi-year growth strategy that will include Ohio and other regions next year. ConcertoHealth will recruit physicians, advanced practitioners (ARNP/PA) and clinical support team members to join its field-based clinical teams.
ConcertoHealth Inc. is the leading risk-bearing provider of field-based complex care for persistently high-cost and rising-risk populations. The company’s multidisciplinary care teams meet patients where they are, with the care they need, whether in the home or hospital. The ConcertoHealth care model improves overall health quality and outcomes with a track record of reducing hospital admits by 47%, readmits by 40% and ER visits by 16% for the most frail and vulnerable populations in America, benefiting patients, payers and provider networks alike.