Eastern Virginia Care Transitions Partnership

SERVICES

EVCTP Delivers Evidence Based Care and Comprehensive Services
to Medicare Advantage, Medicare and Medicaid Eligible Customers

PREVENTION, CARE PRACTICES & HEALTH PROMOTION

  • Patient-centered approach
  • Transportation to physicians and wellness visits
  • Address social determinants of care—meals,home care, and others
  • Stanford Chronic Disease Self-Management
  • Ongoing health assessments and strategies for patient success
  • Preventative care
  • Improved patient and caregiver experience
  • Risk screenings and intervention development
  • Medication reconciliation and management
  • Behavioral health screenings
  • Advance care planning
  • Preventative solutions through education and patient empowerment
  • Outreach
  • Fall Prevention

CARE COORDINATION

  • Pre and post accute care
  • Prevention strategies for Medicare Advantage, Medicare and Dual Eligible participants
  • Registered Nurses, social workers, health coaches and direct care staff utilize evidence based techniques to prevent readmissions, promote wellness and ensure quality

TECHNOLOGY

  • Maintain database for reporting, performance measures and tracking episodes of care
  • Reporting on quality outcomes and quality assurance measures
  • Building to integrate with Health Information Exchange
  • Full service for referrals, billing, reporting and data analytics