What We Do?

1 

Telephone Case Managers

• Direct nurse access by phone for questions, support, and guidance.

• Personalized care plans developed and reviewed regularly.

• Early identification of health changes before escalation to hospitalization.

• Decreased avoidable ER visits and admissions.

• Improved chronic condition control and self-management.

• Strengthened patient–provider communication.

2

Transition of Care

• Coordination of discharge instructions, medication reconciliation, and follow-up appointments.

• Education on warning signs, red flags, and next steps.

• One-on-one post-discharge calls to confirm understanding and support at home.

• Lower 30-day readmission rates.

• Reduced medication errors and confusion.

• Higher satisfaction and confidence in recovery.

3

Chronic Disease Management

• Continuous education and coaching to manage chronic conditions like diabetes, COPD, CHF, hypertension, and kidney disease.

• Regular telephonic check-ins to monitor progress, adjust care goals, and reinforce provider instructions.

• Empowerment to make lifestyle and medication changes that improve long-term health.

• Fewer disease-related hospitalizations and ED visits.

• Better self-management and adherence to treatment.

• Sustainable, measurable improvement in overall health.

4

Health Education and Coaching

• One-on-one nurse coaching focused on nutrition, medication adherence, preventive screenings, and self-care techniques.

• Culturally sensitive education tailored to literacy levels and individual motivation.

• Encouragement and accountability to meet health goals.

• Increased member activation and empowerment.

• Improved quality of life and health literacy.

• Reduced reliance on acute and emergency care.

5

HEDIS® Quality Measures Support

• We partner with health plans to improve performance across key HEDIS domains by:

• Conducting targeted outreach to close care gaps

• Educating members on preventive screenings and follow-up needs

• Supporting medication adherence and chronic-condition monitoring

• Facilitating appointment scheduling and transportation coordination

• Providing data feedback to health plans and providers

• Addressing Social Determinants of Health (SDOH) affecting compliance