Our population health programs focus on frail patients and those with serious illnesses. We use special strategies to assist you in crafting and accomplishing your healthcare goals. Through the use of advanced tools and techniques and a personalized approach, we help you navigate a complex healthcare system and achieve your best possible quality of life.

Through this program, certified clinicians use patient self-management support, motivational interviewing and evidence-based home healthcare best practices to reduce hospital readmissions for those with chronic illnesses, such as heart failure and lung disease. We use a propriety high risk patient identification tool and interdisciplinary conferencing to improve outcomes.

Who we can help

  • Patients with a chronic illness, including Diabetes, COPD, Chronic Heart Failure, Parkinson’s disease and others who could benefit from our home healthcare services or our clinical specialty programs focused on supporting patients and caregivers
  • Patients who have been hospitalized repeatedly
  • Patients who have had a change in medications
  • Patients whose condition is deteriorating
  • Patients who have trouble organizing and managing multiple medications
  • Patients not visiting or calling their MD appropriately
  • Patients with poor health literacy
  • Patients without a consistent primary caregiver
  • Patients depressed or overwhelmed by their treatment regimen

How we can help

Through this program, certified clinicians use patient self-management support, motivational interviewing and evidence-based home healthcare best practices to reduce hospital readmissions for those with chronic illnesses.

Working as part of your team of healthcare professionals, our staff will:

• Check vital signs, oxygen, weight and peripheral edema
• Offer a health literacy screening and tailor education to your needs
• Use motivational interviewing to help you achieve and set goals
• Teach simple and practical tips for needed diet changes and medication management
• Teach physical therapy exercises to increase endurance
• Provide occupational therapy to make activities of daily living more manageable