Care Management & Transition of Care Services

Our care management and transition of care multidisciplinary model produce better health outcomes for patients while significantly reducing hospital re-admission and ER utilization rates.

We target patients in facilities that would benefit most from care management and transition of care services. We utilize the expertise of our clinical pharmacists to provide medication reconciliation services as well as comprehensive medication discharge counseling that includes scheduled telephonic or in-person follow-up appointments within 24 to 48 hours post-discharge.

Our group of experts also work in collaboration with other members of the health care team to address gaps in care, facilitate access to other health and social care needs, address health literacy, provide education, coaching, counseling, and support to patients, their families and caregivers regarding self-care skills and other healthy lifestyle skills. Our team also works closely with prescribers to enhance therapeutic outcomes from drug therapy.

Our care management and transition of care services include medication reconciliation (MED REC) services medication discharge counseling service, prior authorization (PA) management services & medication assistance program, medication adherence (synchronization) services, personal care assistance services, non-emergency medical transportation service, and patient triage services.

We also offer bundled concierge services that included patient education, medication reconciliation, follow-up phone calls, discharge prescription planning and delivery, and home-based medication reconciliation.

Our medication reconciliation process is driven by our clinical pharmacists. We partner with patients, patient’s provider, primary pharmacy, families and caregivers to create a complete, accurate & current medication list. The goal of our medication reconciliation service is to reduce medication errors and adverse drug events at all transitions of care.

Improve patient medication adherence and health outcomes with our medication discharge counseling service. Our Pharmacists equip patients with a thorough understanding of their discharge treatment regimen and provide expectations of therapy. Discharge medication costs are evaluated for less expensive alternatives and eligibility for a patient assistance program to reduce cost. We follow-up with patients by phone or in person within 24 to 48 hours and at 7 days post-discharge to re-enforce treatment plan, address questions and evaluate symptoms for needed interventions.

We can manage your entire prior authorization (PA) process. Our services includes management of PA submission, follow-up, peer to peer consultations, appeals for denials, pharmacy & medical benefit investigation, patient medication assistance program enrollment & support, patient engagement & refill adherence services, PA status updates, pharmacist consultation for medication alternatives and therapeutic drug monitoring service.

Let our professional personal assistant caregivers help meet your unique non-medical or custodial care needs. We provide personal care services to individuals who are too ill or busy to perform activities of daily living. We also provide quality, flexible personal care services to meet the needs of organizations and facilities. We train our staff to handle all levels of your personal care needs, including homemaker services and family-caregiver support services.

Prime Care Health Solutions provides non-emergency medical transportation services to individuals and business clients. Our services include transportation to medical appointments and pharmacy medication pick-up, medication delivery service and many other medical transportation needs. Our transportation services help improve patient health outcomes by reducing transportation related obstacles to accessing care. We help enhance appointment adherence, medication adherence and decrease loss to follow-up by providing convenient and timely access to quality medical transportation service.

When a patient has left your facility or it’s after hours, you can still reach your organization’s operational goals, provide continuity of care, increase patient satisfaction and lower readmissions rates by utilizing our patient triage services. We provide a patient communication platform for non-urgent health and medication questions via phone or secure messaging. We follow your instructions to triage each outreach made by your patient. Patient communications are handled by our triage representative and questions are routed to our licensed healthcare experts to address or direct patient to the appropriate level of care. The details of each encounter are sent to the primary provider for follow-up.