Rather than being provider led, Sage Health person-centered care has the patient in the center of the care team with all care decisions based around the goals and priorities of the patient. Although beneficial for everyone, person-centered care is especially effective in serving those who are most frail and living with multiple chronic conditions. Person-centered care is value-based care because it improves quality of life, reduces healthcare utilization, and lowers the care cost in late life.

We utilize a team-based approach in our patient-focused Advanced Primary Care delivery model and staff interdisciplinary Care Teams to execute our model. Each Care Team is led by a Geriatric Physician or Nurse Practitioner who is partnered with a Registered Nurse, a Medical Assistant, Case Managers and Care Coordinators, Pharmacists, Licensed Clinical Social Workers, Physical Therapists and more and consult with specialty physicians to deliver value- based, coordinated care. At Sage Health we recognize that every patient is different, so what works best for one patient may not work for someone else.

Our approach to holistic care, also known as whole-person care is viewed by the lens of the senior adults medical, emotional, social, and behavioral health needs. The non-medical factors known as SDoH, influence as much as 80 to 90% of health outcomes. It provides us feedback which allows us to intervene when needed – usually before an acute need arises. And by being in the home we can identify fall hazards, the contents of their refrigerator and medicine cabinet that helps give us the entire picture of the patient and their surroundings and how they impact their health and wellness.

Although adults with complex needs share some common characteristics — like frequent use of healthcare and social services — the needs of specific segments within this population vary considerably. We utilize technology and data to identify high-need patient subsets and segment them into subgroups based on common attributes. Then we identify, stratify and engage the right patients at the right time by designing interventions that are most likely to benefit each individual to improve costs, engagement, satisfaction and health outcomes.

Access to preventive care is the foundation of good population health management. It’s critical for chronically ill patients and for healthy patients, whether or not they routinely seek out care themselves. Our evidence-based preventive care programs, such as cancer screenings, chronic disease management programs, transitional care management (TCM), and regular wellness assessments catch rising risks early enough to avoid hospitalizations, ED visits, and other high-cost interventions.

Care coordination is an integral part of providing quality healthcare to senior patients, many of which are managing a chronic health condition, and to prevent care gaps that can often lead to adverse outcomes. Our integrated care delivery model harnesses the power of teamwork to meet the medical, psychological, social, and personal health needs of the seniors we serve.

Our cloud-based Telehealth platform is comprised of Virtual Care and Remote Patient Monitoring (RPM) technologies that engage the right patients at the right time and in the right place (home) to enable patients to age in place, reduce ED utilization, reduce readmissions, reduce overall cost of care, improve access to care, and increase patient and/or caregiver satisfaction and engagement.

These models of care approaches lead to achieving the Triple AIM of healthcare of (1) improving the patient experience; (2) improving the health of populations; and (3) reducing the per capita cost of healthcare. This improved quality of care aligns incentives with payers in a value-based reimbursement environment that rewards Sage Health for improved health outcomes of Medicare beneficiaries.