Population Management

Maxlink CareTeam 365 is a direct communication service partner to hospitals, Health Plans, Physician Practices. We offer patient monitoring, daily patient assessment and medication management via scheduled daily phone consultations to the patients. In today's value-based healthcare environment, where revenues depend on fast and effective identification and engagement of at-risk patients Maxlink Health Care Team 365 is the perfect solution.

In order to close the gaps in care, monitor patients' status and conduct targeted outreach without any sophisticated technology except a simple phone consultation. This is especially helpful for patients that are not techno savvy and majority have no smart phones either. Maxlink CareTeam 365 partners with our clients to offer direct patient communication 7 days a week 365 days of the year. All that a patient requires is a regular landline or a cell phone where our dedicated RN care coordinators, Nurse case managers and Pharmacist can reach out and perform phone assessments, guide, motivate, monitor the patient and identify potential health risks and report the findings to Care providers / Physicians' offices for timely intervention to avoid Emergency room visits and hospital readmissions.

Our offerings include the following:

  • High Risk Population Care Management
  • Post-Discharge Outreach and Management / Transitional Care
  • Preventive Care Program for low risk population management

High risk population care management

Identifying at-risk patients and gaps in care

  • A CareTeam365 RN Case Manager is assigned to certain high risk patients to work with. The RN Case Manager engages with a pool of patients that have higher than average resource consumption and emergency department use, as well as an increased likelihood to be admitted or readmitted to the hospital.
  • RN Case managers and RN Care Coordinators connect with patients to understand and resolve each individual's unique barriers to care and then follow up with the patient regularly via phone consultations. If needed a Nutritionist, Health Coach are also involved to ensure the patient is proactively engaged in self-care.
  • Any significant information captured during patient interactions is shared with the Care providers.
  • Moving the high-risk category patients to becoming self-sufficient in their care and improve patient engagement in self-care and disease management to reduce hospitalizations, avoidable emergency room visits and avoidable readmissions.
  • Our assigned CareTeam365 Pharmacist will ensure that individuals understand their medication list, reasons for the meds and outcomes of non adherence along with dosage and usage reminders.