Care Management

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Saisystems Health takes a holistic patient approach with a focus on medication and treatment adherence, self-management skills and behavioral change. We build targeted care management programs for high-risk patients that improve health outcomes and reduce costs for all healthcare stakeholders, including Medicare and Medicaid.

Approach

Why

Patient-centered, accountable care and value-based reimbursements are converging under the umbrella of population health management. Saisystems Health provides the information that consumers and health organizations need to manage their operations in a singular, secure location.

Who

Care teams consist of a care coordinator, nurse practitioner and social worker. Teams have web-based access to clinical and financial information to manage patient health. Whether through an interactive dashboard or self-service analytics, each element leverages the same integrated data set.

How

Our integrated system streamlines the care management process for all healthcare stakeholders to reduce costs and improve care. We calibrate an in-depth understanding of patient populations by identifying those at-risk, employing personal health nurses and enabling provider coordination.


Risk Stratification

Risk stratification levels are based on a complex and proprietary algorithm that determines an exact acuity score, and stratifies patients in accordance to four levels of care. This groups members by risk and need, allowing for personalized care plans and staff workflows. Our software considers both medical and social aspects of the patient population in a three-step process.

Levels 3 and 4 – High-Risk

The care for these patients is delivered in-person at home, in the community or at physician offices. Community-embedded care delivery is carried out by a nurse practitioner, social worker and care coordinator. The visit schedule varies based on the member’s acuity and needs, but a minimum of one in-home visit by the care manager and one physician office visit by the care manager or social worker are required.

Levels 1 and 2 – Low-Risk

Care is mostly delivered telephonically, depending on the severity of needs and under the possibility of conditions worsening and acuity score risings. This program is designed for self-management, but still consists of a nurse practitioner, social worker and care coordinator like the more at-risk levels. There is a minimum of one call per month, either by the care manager or social worker, until the patient is further cleared. Once stable, calls take place every other month based on the patient’s needs.


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Our care management extends past the walls of the practice into the community to give a holistic a view of the patient in-between visits. We work with patients throughout the entirety of their disease journey to improve adherence to treatment and medications, as well as health outcomes. Supporting patients for a life cycle bridges the previous lack of care coordination and avoid serious medical consequences.



Focuses