When Clare Medical dispatches their clinicians and other healthcare professionals to house-bound seniors across New Jersey, it relies on technology to connect its mobile team and track patient progress.

Chief Operating Officer Deborah Scott says its high-touch high-care model delivers results for its patients, the majority of whom have multiple chronic conditions.

She says hospital admissions and emergency room visits have dropped by more than 40 percent, according to an internally designed pilot of patients enrolled in their chronic care management program.

“Boots on the ground”

“We’ve got boots on the ground to provide care,” Scott says. “Seeing patients in a timely, proactive manner produces results. Sometimes a phone call isn’t enough and a face-to-face visit is needed.”

In contrast to traditional practices which are not exclusively focused on providing in-home or on-site medical care, “our model allows us to be more responsive and see patients sooner,” she says. “On average, we’re seeing patients within 1 1/2 days.”

Clare wants to broaden the partnerships it has established with hospitals, subacute rehab facilities and skilled nursing facilities across the state. It recently joined Prepared Health’s  network, a HIPAA-compliant electronic platform, to help build those partnerships and facilitate the patient referral process from its affiliates.

Filling gaps in care

“We can fill care gaps for our affiliates,” she says. “It’s all about preventable hospitalizations. We are a solution for them.”

Another benefit: transparency across the care continuum.

“Through Prepared Health, we envision streamlining communications and having full transparency on the status of each discipline, whether it’s home care, durable medical equipment or subacute rehab,” she says. “By utilizing Dina, everyone involved can assess how a patient’s care is being managed.”

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