Ready is a community-based care model that places Responders (with backgrounds as EMTs, Paramedics, and MAs) in the home paired with synchronous telehealth providers (Physicians, NPs, PAs), RNs and LCSWs.
This innovative integrated care team empowers rising-risk populations to regain control of their health, re-engage with the healthcare ecosystem, and remain out of higher-cost, higher-acuity care settings.
Our strengths as a community-based provider position us to positively impact several key challenges that compromise patient health today:
• Social, financial, and trust factors among disenfranchised communities have historically been barriers to engagement with the broader healthcare system.
• Many MCD, Duals, and MCR patients are without a named or attributed PCP or have not seen one in 1+ years.
• Unconnected patients are more likely to visit high-cost, high-acuity settings for low-revenue, non-emergent needs.
• Lack of PCP connection, lower medical literacy, high caregiver strain, and other risk factors post-discharge can result in preventable readmissions.
• Incomplete diagnoses, documentation of chronic conditions +SDoH factors among hard-to-reach populations result in:
• Partial visibility into patient needs
• More severe complications
• Higher barriers to effective care planning
• Lost revenue for health plans / ACOs
Empowering rising-risk and high-risk patients to regain control of their health and re-engage with the broader healthcare ecosystem.
Ready at Discharge: 30-day post-inpatient readmission reduction program that incorporates evidence-based screening tools to assess clinical, behavioral, and social health while re-engaging patients with their healthcare team.
Community Care: works collaboratively with high-utilizing patients, providers, and health plans to reduce ambulatory care-sensitive acute utilization while improving patients' self-efficacy concerning their health.
Asynchronous Care Services:
• POC Testing
• Screening Assessments
• RPM Onboarding
• Vaccinations (availability varies by market)
quality and chronic condition management
engagement strategy for harder to reach populations
Mobile, on-demand capabilities (diagnostics and therapeutics) for current and former Bridge Care patients aimed at preventing escalation to acute care.
On-demand care: Responders visit a patient’s home and set up a virtual visit with a clinician who can provide POC diagnostic testing and non-emergent treatment capabilities.
*Data collected from Community Care program launched with national health plan in Nevada
**Data collected from program launched with a major health system in Louisiana.