Services

Closing gaps in care to create better outcomes

Supporting Value Based Care

Simple Community Health supports the goals of value based care through a technology enabled team that closes gaps in care to create better outcome. As a Community Care Management Organization (CCMO) our platform supports providers and health plans in managing their complex or targeted populations across a virtual and in-home suite of services.

Our team follows the existing plan of care, and augments the support services to reduce the total cost of care. We do this by creating a framework of management and interventions that enhance healthy behaviors and lifestyle while monitoring for changes in condition which signal serious concerns.

Our framework combines the expertise of providers and care navigators with the tools to monitor and respond to create a framework for sustainable care management.

Physicians

Providers

Our providers manage the team to ensure care pathways, program planning and quality are aligned to provide the strongest service and outcomes for patients and partners.

Physicians

Nurses

The Simple Community Health nursing team play a vital role in the success of our programs. Our nurses review all incoming patient data, manage the care navigation teams and are available 24/7 to support all patient needs.

Care Navigators

Our care navigation team is the core of our operation. The team is comprised on professionals who are trained in our processes, and then integrated into each customer team based on the design and outcomes for each program. Our navigators play key roles ranging from monitoring patient vitals, communicating with providers and partners, and being available 24/7 to speak with our patients when the have questions or concerns.

Community Care Specialists

Our organization understands the importance of relationships and understanding when it comes to successful outcomes for programs and people. Our specialists strive to make the lives of our patients better by understanding their current condition, providing comfort and support as needed, and escalating for interventions when necessary. They work to make health care easy and transparent to the people we serve, and that is the key to driving successful outcomes for our partners.

Behavioral Health Specialists

Many of the challenges facing our patient population are driven by behavioral health concerns. Our team inclufdes specialists who can support our nurses and navigators in recognizing and managing critical issues and directing them to the appropriate resources. In addition, our teams can manage patients through the Medicare Chronic Care Management program for targeted populations.

Program Managers

Our programs are built on the principles of marrying clinical and operational excellence. Our program managers are responsible to understand the full scope of each engagement, the clinical responsibilities and the goals of the program for our partners. Each PM leads a detailed implementation process, and maintains regular contact with each partner to communicate key data, identify and resolve challenges, and work with the executive team to develop improvements to each program.

Data Analysts

Data analytics and assessment are essential to our partners and our team in understanding and improving the health and outcomes of the people and programs we serve.

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