Clinical Model

The CareMore Commitment Statement

The path to profound change is made easier if someone leads the way. At CareMore, we purpose to be the beacon for others to follow in transforming American healthcare.

Our Commitment is to:

  • Lead and excel in health outcomes while reducing total cost
  • Care for the dignity and health of the whole person—body, mind, and spirit
  • Thoughtfully challenge the status quo

Through a Model of Care That:

  • Makes decisions and advances innovations based on medical evidence, data, and common sense
  • Delivers a seamless experience that is uniquely tailored to each individual and family
  • Restores the joy of delivering healthcare

Philosophy

Our clinical model is an innovative healthcare delivery approach that proactively addresses the health needs of our members.

We use a self-reinforcing and integrated suite of clinical programs and services where all clinicians and non-clinicians are aligned and coordinated as a team. This is different from the traditional healthcare model that is fragmented and inefficient. In the traditional model, patients with serious conditions see an average of 11 different doctors, resulting the lack of coordination that can leave patients frustrated and in financial catastrophes for no fault of their own. Poorly managed and redundant care resulting from this fragmentation increases health care costs and reduces patient care outcomes.

Additionally, the traditional system does not allow for consistent contact with healthcare professionals. Management of chronic conditions is very difficult and adherence drops as a result, causing chronic conditions to progress far more rapidly. Patients and families experience the loss of independence and wealth, which is accompanied by psychological and emotional stress. The very individuals that need the most attention end up becoming victims of the system set up to care for them. This is the opposite of what each patient deserves.

At CareMore, we aim to give patients the care they deserve in a sustainable and coordinated manner.

We are proud of our obsessive attention to detail when it comes to providing all needs for the patient’s body, mind, and spirit.

Our trained clinicians serve as culture carriers in everything they do and to everyone with whom they work. Our goal is for CareMore’s philosophy and clinical culture to serve as a catalyst for transformation of the healthcare system. We do it with the following team:


1.

Neighborhood Care Centers & Care Teams

Neighborhood Care Centers are outpatient facilities designed to give patients additional attention with their chronic disease conditions and teach patients ways to improve their overall health.

  • Instead of asking patients to travel far and wide over several days to see different doctors and specialists for their medical care, the Care Center teams revolve around the patient in a one-stop facility.
  • Feature teams of Nurse Practitioners, Medical Assistants, Dietitians, Exercise Specialists, and Case Managers to coordinate patient care and collaborate with Primary Care Providers and Extensivists to meet patient needs.
  • Each Center is equipped with smart patient-care technology that allows all team members to monitor patients’ health when they are at home. We utilize these technologies to catch any warning signs early and make sure our patients have the best chance of avoiding the hospital.
  • Care Centers feature primary care medical services as well as podiatry, mental health services, diabetes management, wound management, hypertension management programs, prevention services, and many others.

2.

Case Management

Case Management teams coordinate care across all parties including providers, hospitals, long-term care, and specialists.

  • Take ownership of the patient at the point of admission and ensure that each patient receives a high standard of care and his or her conditions are properly managed.
  • By asking the right questions, Case Management helps realize the full potential of cooperation between a wide range of caregivers to make sure no patient falls through the cracks between different part of the healthcare system.
  • Lead daily telephone rounds with Extensivists for all inpatient admissions, prepare both patient and family for discharge, coordinate all visits necessary for proper healthcare, and dispatch any necessary services for the patient to avoid readmission into the hospital.
  • Provide close monitoring of each patient to proactively identify at-risk members and potential red flags. They monitor and manage care for a patient for as long as that patient is a CareMore member.

3.

Primary Care Provider

Primary care providers serve as the first contact for our patients, providing the level of touch that every patient deserves.

  • Frontline player in CareMore’s delivery of care
  • Principle neighborhood provider type for all CareMore patients
  • Supported by interdisciplinary care teams, Care Centers, and Extensivists for advanced patient care and chronic disease management

4.

Extensivists

Extensivists extend the role of the Primary Care Provider during and after hospitalization to ensure sustained care.

  • Assume control of the entire end-to-end inpatient stay (diagnostics, PCP communication, specialist consults, family interaction).
  • Are in constant communication with the Primary Care Provider and the Care Teams, and serve as the link that ensures seamless and effective transitions in care.
  • Post-discharge, Extensivists follow-up with every patient to ensure that proper attention specific to the patient’s condition is given to minimize the chance for re-hospitalization.
  • Retain the lead physician role during Skilled Nursing Facility stays and manage high-risk outpatient events such as dementia evaluations, transplant evaluations, bariatric surgery evaluations and falls prevention.