Our Connected Care and Transitional Care programs work as an extension of your team, allowing you to concentrate on the patients in your office while we care for those who are unable to visit the clinic. We partner with you and keep you updated on the progress of your patient.
Connected Care
The House Calls team works directly with your practice to provide care to patients unable to come to your office because of increased frailty, a one-time condition (e. g., surgery that makes travel difficult) or exacerbation of a chronic condition.
Our team:
- Sends progress notes to your practice after every visit
- Evaluates patient progress every three months for return to your practice
While patients are on service with House Calls, they are managed by our team:
- This ensures proactive medication management and reduces the risk of over prescribing resulting from co-managed primary care.
- Patients participating in this program call House Calls directly with any medical concerns.
During the time the patient is on our service, House Calls will provide chronic care management services, as appropriate. Patients transition out of House Calls and back to your practice as soon as they are medically stable to travel.
Transitional Care
House Calls provides transitional care visits for your patients who are leaving the hospital but are unable to easily get to your office for appointments.
Our team:
- Visits your patient in their place of residence within 24-72 hours of hospital discharge, based on the clinical needs of the patient
- Conducts comprehensive medication reconciliation
- Ensures all necessary services have been ordered and started
- Provides all necessary medical visits until the patient is able to safely return to your office
During the time the patient is on our service, House Calls will provide chronic care management services,
as appropriate.
Referrals
To refer a patient to House Calls’ Connected Care or Transitional Care programs, please fax the following information to (701) 356-1603:
- Patient demographics to include all current insurance information, as well as the name and contact information for the primary caregiver or POA
- An order with current diagnoses
- A comprehensive medication list
- Recent records for hospital stays, office visits and any testing that has been completed