ABOUT CENTRALIZED CARE MANAGEMENT

We are honored to provide you with comprehensive primary care. Compass Medical, along with your insurance carrier has identified the care of chronic health conditions as an important goal.

Chronic conditions are ongoing medical problems that must be managed effectively in a partnership between the health care team and the patient to maintain the best possible health.

To be proactive with your healthcare, the Compass Medical Team has designed these programs to collaborate as an organization to provide you with the most compassionate care and patient-centered experience.

Sometimes, an effort like this,

TAKES A VILLAGE.

CENTRALIZED CARE MANAGEMENT SERVICES

CHRONIC CARE MANAGEMENT (CCM)

This program will allow you to take control of your health with the support of your Care Team. We will work with you on your schedule and your priorities to provide the following:

  • Patient-Centered care plan
  • Telephone calls in between office visits to help you manage your chronic health conditions
  • Consistent communication and involvement between you and your care team
  • Coordination of care with outside providers
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REMOTE PATIENT MONITORING (RPM)

Remote Patient Monitoring is a program using technology that enables your care team to monitor and collect your important health readings such as blood sugar, blood pressure, and weight outside of a traditional healthcare environment, in other words in your own home or office. Using cellular (4G) devices, your readings are sent automatically with ease directly to our Care Managers for review. Through RPM, your Provider has access to robust, detailed, and often real-time physical data sets. This, in turn, gives a clearer and holistic view of your health and treatment progress and enables timely interventions and more informed care plans.

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TRANSITIONAL CARE MANAGEMENT (TCM)

Transitional care management program is designed to facilitate a patient’s transition home from an inpatient stay in a hospital or skilled nursing setting.  A nurse will contact the patient to address any issues, review medications, and schedule a follow-up visit with the primary care provider within 2 weeks of being discharged. The goal of this program is to prevent rehospitalization and ensure the patient has immediate access to care.

CENTRALIZED CARE MANAGEMENT PILOT PROGRAMS

Compass Medicals Centralized Care Management Services are piloting other programs in addition to Chronic Care Management and Remote Patient Monitoring. This program is currently only offered by some of our providers to ensure an exceptional experience for our qualifying patients. This program is:

EMERGENCY ROOM FOLLOW UP

Telehealth visits are offered to our patients post-emergency room discharge. This is a pilot program currently underway with several of our primary care practices. This program has received positive patient feedback, positive outcomes, and the prevention of clinical complications.

MEET THE

CENTRALIZED CARE MANAGEMENT

COLLEEN DANIELS, NP

Internal Medicine

DEBRA LANDRY, DPN

Chronic Care Management

MARIANNE RIVARD, NP

Centralized Care Management

CENTRALIZED CARE MANAGEMENT LOCATIONS

Centralized Care Management is a remote service Compass Medical provides to eligible patients of all our primary care locations, using telemedicine. The goal of Centralized Care Management is to bring care to YOU in the comfort of  YOUR home through our telemedicine technology. Patients are able to meet with their Centralized Care team remotely via telephone, video, and are monitored using a 4G medical device.

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