- Preventive care including health assessments, immunizations, and functional assessments
- Medication management and adherence strategies
- Reduction of emergency department use and hospitalization
- Post hospitalization discharge follow up
- Hospital admission avoidance program
- Readmission reduction program
- Reduction of re-hospitalization for medication-related issues, co-morbidities, or other ambulatory sensitive conditions
- Enhanced patient access to reduce need for emergency department care
- Patient Stabilization- enhanced path to recovery and health status improvement
- Diagnostic/Screening Tests — Vision, hearing, spirometry, EKG and basic primary care.
- Annual Basic Health Assessment and Well care.