Manage the clinical needs and well-being of members with complex chronic conditions who reside in nursing facilities through Signify Health’s multi-disciplinary approach. By looking at medical needs and well-being holistically, our clinicians address key elements of the patient’s care plan, including medication adjustments, adherence to care plans, and patient behavioral and nutritional needs, to close gaps in care.

Benefits:

• Reduce re-admissions

Reduce costly re-admissions using predictive analytics, post-acute member engagement, and coordinated readmission reduction programs.

• Support the whole person

Proactively address social determinants of health (SDOH), behavioral health, skill needs, and clinically-appropriate hospice transitions through an integrated approach.

• Enhance member engagement

Connect members to an interdisciplinary care team that builds trust and coordinates with the facility team, PCP of record, and other key stakeholders to improve quality of life.

Features:

Overcome today’s fragmented healthcare model with a multi-disciplinary approach that addresses the clinical and social needs of patients with complex chronic conditions. Our providers engage where it’s most convenient for patients and their families, including resident and palliative care facilities.

• Patient segmentation

Identify and stratify members by risk to close gaps in care.

• Personalized care

Enhance the member experience with face-to-face clinician visits.

• Education as prevention

Focus on follow-up behavior and education as preventative care.

• Non-medical health needs

Uncover social determinants of health such as spousal support or food insecurity.

• Medication review

Review medications and increase treatment adherence.

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