The USMM Accountable Care Partners is organized to focus specifically on a subset of Medicare beneficiaries who have multiple chronic illnesses, require multiple medications, and demonstrate multiple functional impairments. Because this population is so specific, we have developed a Clinical Guidelines Manual that uses current evidence-based medical standards and practical experience gained through 20 years if patient care performed by the nation’s largest physician home-based primary care practice.
We are a home-based accountable care organization.
The very nature of home-based primary care provides enhanced access to health services and quality of life for complex populations by removing barriers to receive care in the home. By providing services in the home, patients are truly engaged in their medical needs. With visits to a patient’s home, USMM Accountable Care Partners is able to see factors that may be virtually impossible to identify in an office setting. Here, the physician will be able to determine factors might represent barriers to treatment adherence and health outcomes. In home, a physician has a better capacity to accurately identify and meet home health care needs, and mobilize other supportive services locally available, in the interest of promoting clinical stability.
Personalized Prevention Plan
The personalized prevention plan includes a risk vs. benefit discussion as does the patient’s expressed belief and goals. This approach speaks to all manner of individualized, personalized, gender specific and diversity directed considerations around the patient’s psycho-social and medical needs. We will adjust the frequency of visits according to the patient’s medical needs. Providers work with Area Agencies on Aging and other social safety-net agencies to identify those who do not have access to primary care.
Patients will be supported by a 24×7 Patient Care Center that utilizes physicians, nurses patient care coordinators, community advocates, and ancillary specialists to engage the appropriate resources to support the patient’s health and wellness.
Patients are provided access to medical record information both online and hard copies.
Our goals is avoid institutionalization, including hospital or skilled nursing facilities/long term care.