• 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.