In-Home Care Management
Successful Readmission Aversion

Our Emergency Trained Physicians and Nurses have the experience and expertise to assist our clients in making informed decisions about their healthcare choices. This team represents a diverse group of clinicians assembled to provide leadership and guidance to the patients we serve. Through a home based approach our clinicians provide immediate care coordination as well as the guided support many individuals require as they are discharged from an acute care facility.

How We Provide Value
  • Emergency Medicine Physician (EMD) Led Teams
  • In-Home patient Engagement
  • 24 Hour Care Team Access
  • Crucial Care Connect Smart Device given to each patient
  • Proprietary Real-Time In-Home Risk Stratification Tool
  • Emergency Medicine Clinical Protocols
  • 9 Years Actuarially Validated Savings
  • Remote Clinical Monitoring
  • Physician Directed Care Planning
  • Network Specific Real-Time Care Coordination Platform (Pathfinder™)
Crucial Care Without Walls Care Model Diagram
Patient Care Case Scenarios
Typical Situations for Crucial Care Without Walls
Crucial Care Without Walls Nurse At Patient's Door
ER-Level In-Home Care Management
Patient care scenario case one
The Patient

68 year old female discharged from SNF six weeks post Hip replacement.

The Assessment

Physician assigns a risk assessment level 2 indicating homehealth provider has provided nursing but not physical and occupational therapy due to lack of orders. As a result, patient has not bathed and is at increased fall risk. Additionally, Medication Reconciliation has uncovered patient needing immediate refill of cardiac medication.

The Solution

Crucial Care Physician rapidly intervenes by writing both medication and therapy orders and coordinates efforts with PCP and Homecare. Therapy and medication arrive at patients home later that afternoon.

  • Emergency Medicine Physician (EMD) Led Teams
  • Crucial Care Connect Smart Device given to each patient
  • 9 Years Actuarially Validated Savings
  • Remote Clinical Monitoring
  • In-Home patient Engagement
  • Proprietary Real-Time In-Home Risk Stratification Tool
  • Network Specific Real-Time Care Coordination Platform (Pathfinder™)
  • Physician Directed Care Planning
  • 24 Hour Care Team Access
  • Emergency Medicine Clinical Protocol
Crucial Care Without Walls Nurse Helping With Care Connect Device
Patient Needs Immediate Intervention
Patient care scenario case two
The Patient

65 year old diabetic female two days post discharge notices a developing “sore” and activates the Crucial Care Connect Smart Device.

The Solution

This provides immediate access to the Clinical Care Team, which includes the Crucial Care Emergency Medicine Doctor. The patient’s RN arrives to assess patient concern, and the Physician provides video-based confirmation of developing pressure wound. Clinical Care Team uses Pathfinder™ Technology to identify the right home based wound care provider for quick intervention.

  • Emergency Medicine Physician (EMD) Led Teams
  • Crucial Care Connect Smart Device given to each patient
  • 9 Years Actuarially Validated Savings
  • Remote Clinical Monitoring
  • In-Home patient Engagement
  • Proprietary Real-Time In-Home Risk Stratification Tool
  • Network Specific Real-Time Care Coordination Platform (Pathfinder™)
  • Physician Directed Care Planning
  • 24 Hour Care Team Access
  • Emergency Medicine Clinical Protocol
Patient On Oxygen Waits by Window
Real-Time Network Management
Patient care scenario case three
The Patient

71 year old female with COPD is being followed by the Crucial Care Without Walls Team.

The Assessment

During an In-Home visit, patient notifies RN that current Oxygen Vendor has missed second straight portable tank delivery. This member is unable to leave the home without a portable tank due to their oxygen dependency.

The Solution

Clinican consults Crucial Care Physician who accesses Pathfinder™, our Care Coordination Engine, and orders Home Oxygen from another provider within the Humana network. This provides the Aetna member with a higher performing oxygen supplier to allow compliance with followup appointments.

  • Emergency Medicine Physician (EMD) Led Teams
  • Crucial Care Connect Smart Device given to each patient
  • 9 Years Actuarially Validated Savings
  • Remote Clinical Monitoring
  • In-Home patient Engagement
  • Proprietary Real-Time In-Home Risk Stratification Tool
  • Network Specific Real-Time Care Coordination Platform (Pathfinder™)
  • Physician Directed Care Planning
  • 24 Hour Care Team Access
  • Emergency Medicine Clinical Protocol
Crucial Care Without Walls Telemedicine Patient
ER-Level Monitoring and Assessment
Patient care scenario case four
The Patient

Newly enrolled 72 year old hypertensive female.

The Assessment

Patient scores a 4 on the Crucial Care Real Time Risk Assessment Tool which indicates the need for a 30 day collection and transmittal of biometric data, health assessment information, and monitored changes in existing health patterns.

The Solution

Patient is given access to our easy to use remote clinical monitoring platform. On day 21 patient data indicates blood pressure above Physician assigned value. Monitoring RN escalates to EMD and initiates clinican-directed interaction via videoconference.

  • Emergency Medicine Physician (EMD) Led Teams
  • Crucial Care Connect Smart Device given to each patient
  • 9 Years Actuarially Validated Savings
  • Remote Clinical Monitoring
  • In-Home patient Engagement
  • Proprietary Real-Time In-Home Risk Stratification Tool
  • Network Specific Real-Time Care Coordination Platform (Pathfinder™)
  • Physician Directed Care Planning
  • 24 Hour Care Team Access
  • Emergency Medicine Clinical Protocol
Dashboard Level Patient Care Reporting
learn more about the virtual readmission shield report