Delivering Extra Support for Patients and Practices
Our clinical team provides patients with a range of clinical support designed to help our provider partners address the diverse healthcare needs of their patients and deliver better health outcomes. Committed to supporting providers in the delivery of personalized care, we work as an extension of the primary care practice to provide patients with care coordination and care navigation services to help ensure their well-being.
A Range of Clinical Services to Treat and Support Patients
Working with primary care providers, we identify and support high-risk patients through our NCQA-accredited Complex Care Management (CCM) program. By targeting interventions and closing gaps in care, we aim to work with our provider partners to lower costs and improve outcomes. Our care management team, comprised of nurses, pharmacists, social workers, behavioral health specialists, and clinical coordinators, works closely with practices to deliver personalized, whole-person care via robust, evidence-based programs and care pathways.
Advanced Illness Management (AIM)
Our AIM pathway supports patients with complex chronic illnesses such as cancer, heart disease, COPD, or dementia, ensuring personalized care and assistance. A multidisciplinary team supports our provider partners by connecting patients to palliative care resources that provide symptom management, goals of care conversations, and caregiver support.
Comprehensive Medication Management (CMM)
CMM services are designed to optimize medication regimens and reduce adverse drug events. Clinical pharmacists use evidence-based best practices and innovative technology to provide personalized medication management and work with our provider partners to ensure that patients receive safe and effective medication therapy.
Heart Failure
Patients in our Heart Failure pathway receive tailored interventions designed to enhance their outcomes and reduce avoidable hospitalizations. Our care coordination teaches patients to identify symptoms, optimize medication regimens, and encourage medication adherence. We support patients and their caregivers on self-care strategies and when to contact their providers upon recognizing the signs of worsening heart failure.
Transitions of Care
Our Post-Acute Care/SNF program supports our provider partners in reducing avoidable admissions, emergency department visits, and other unnecessary health system utilization by streamlining care transitions. With expert, evidence-based care and care navigation, patients seamlessly transition from the hospital to a skilled nursing facility or to home, ensuring continuity of care and promoting better health outcomes.
Fall Risk Reduction
Tandigm screens all CCM patients for fall risk using CDC STEADI guidelines. Patients identified as at-risk will receive patient and caregiver education on fall-risk reduction and have a primary care visit conducted to address any clinical risks.
Direct to SNF
Where appropriate, our team can facilitate direct admission for patients of Tandigm providers to one of our partner skilled nursing facilities, preventing unnecessary hospitalizations. Our Direct to SNF program reduces both the patient’s days away from home and the total cost of care. A simple, one-call process to CCM lets providers easily obtain facilitated admission and bypass unnecessary inpatient stays.
Managing Medical Costs
In addition to clinical support, we work with practices to manage costs while improving care delivery. Our Medical Cost Management (MCM) initiatives are driven by interdisciplinary collaboration and an outcome-oriented focus. Through a precise scope of work and dedicated workgroups, we address high-impact cost areas to drive cost savings and improve overall healthcare services. Our Value Solutions, Network Solutions, and CCM teams provide support and guidance to practices ensuring successful implementation of MCM initiatives.
“Tandigm provides us with an unparalleled care team and an extensive network of providers. Their comprehensive suite of supplemental care services enables us to manage patients more efficiently across the spectrum of care. The integration of advanced analytics and reporting further enhances their effectiveness, creating a remarkably powerful combination.”
Frankford Avenue Family Practice, Pinnacle Physicians Group
Interested in learning more about our Clinical Support?
Reach out to discover how our comprehensive and tailored services can support your practice.