Spiras Health is the premier next generation care management organization delivering nurse practitioner led in-home specialty care, utilizing predictive analytics and employing smart use of technology for members with advanced chronic conditions, specifically COPD and CHF made more complicated by co-morbidities and SDoH. The Spiras Health Solution combines monthly in-home services, telehealth, 2-way digital communications, and remote monitoring longitudinally. By treating patients with a whole-person approach through multiple modalities, developing clinician/patient relationships, and extending specialty services such as pulmonology, cardiology and palliative care into the home, Spiras Health is able to support adherence to treatment plan, coordinate care, communicate and collaborate with PCP/SCP and other care team members. The results are enhanced quality of life, improved patient/provider satisfaction, total cost of care reduction, and increased communication, coordination and collaboration among care team, patient, caregivers and community and referral back into a health system's ecosystem for continuity.
Pop health platform, ADT
EMR Integration & Relevant Hardware:
Use case dependent
Desktop, Mobile / Tablet (web optimized), Mobile / Tablet (native app)
Spiras Health is generating significant savings to Medicare Advantage health plans. The unique model consists of the following:
1. Predictive analytics to identify the most appropriate members who will benefit from Spiras and who are at highest risk of incurring avoidable spend
2. Multi-modal approach to care delivery: nurse practitioner driven care, delivered in the member’s home through market-based RTs/nurses; augmented with smart use of technology in the form of tele-video conferencing, 2-way digital communication and remote patient monitoring
3. Provider and Health Plan care coordination and collaboration, closing the loop with community provider
4. Value creation through cost reduction in ER/hospital avoidance, revenue increase through member acquisition/retention, support of Star gaps closures and HCCs, quality metrics impact
While physician offices closed, hospitals and ERs redirected their admitting criteria and resources to patients affected with COVID, citizens were mandated to "shelter in place", and fear of the unknown paralyzed communities, many people were forced to either delay or completely avoid seeking treatment. Patients with COPD, made more complex by multi-morbidities and social determinants of health, do not have the luxury to delay or stop care. Their conditions require ongoing access to care and adherence to treatment plan. Without it, the result is often an ER visit or hospitalization. These patients are also at the highest risk for a negative outcome if they contracted COVID-19. Spiras Health's multi-modal care delivery approach allows patients to receive care in their homes and telemedically, and ongoing monitoring through digital communications and remote monitoring make it possible to regularly monitor a patient's condition allowing for early intervention of symptom exacerbations. The result is ongoing adherence to treatment plan and risk mitigation. During the time of COVID-19, our patients experienced NO disruption in care.
Patients dealing with chronic illness, specifically COPD and CHF, with multi-morbidities and social determinants of health.
Medicare and Medicaid Health Plans and Direct Contracting Entities
Spiras Health is a next generation care management and care delivery provider bringing specialized services to members at home. Spiras focuses on members at highest risk of incurring avoidable spend due to unnecessary utilization of ER and hospital, primarily as a function of poor adherence to treatment plan and uncontrolled symptom exacerbations.
This solution begins by targeting patients with diseases of the heart and lungs (CHF/COPD) made more complicated by multiple co-morbidities and social determinants of health. However, care for all conditions is provided - with a whole-person approach.
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