Complex care and serious illness care are two of the few areas in healthcare where the quality of care for patients can be significantly improved while simultaneously lowering costs. Patients with complex conditions drive significant costs and roughly 25% of all traditional Medicare costs are spent in the last year of life. Patients may experience unnecessary or unwanted hospitalizations, skilled nursing facility stays and ER visits, as well as undertake treatments that may conflict with their goals of care and fail to prolong their lives. Patients facing a serious illness also experience severe symptoms like pain, nausea, constipation and shortness of breath that frequently go untreated, and both patients and their families often wrestle with complex emotions including fear, anxiety and grief.
Aspire Health’s Solution
Aspire Health has built a network of physicians that provides comprehensive medical care for patients with complex conditions or facing a serious illness. Aspire’s team of nurse practitioners, nurses, and social workers is led by a board-certified physician. Our clinicians are available 24/7 to support our patients. Aspire’s clinicians are experts in symptom management, patient-family communication, advance care planning, and medical crisis prevention and urgent response.
Although it can be modified to meet the needs of specific health plans, Aspire’s typical service includes:
- Outreach to primary care physicians, specialists and other community providers as well as highly predictive clinical and claims-based patient algorithms to identify patients who might benefit from Aspire’s services
- A dedicated, individualized care team for every patient that includes a physician and nurse practitioner as well as registered nurses and social workers
- An initial comprehensive assessment by a nurse practitioner that examines all aspects of a patient’s status (e.g. physical, psychosocial, emotional, spiritual) and accurately captures all of a patient’s existing conditions
- A personalized, comprehensive care plan for each patient based on that patient’s specific goals and needs; this care plan is developed in consultation with the patient’s PCP and specialists, who are kept up-to-date on and involved in any future changes to the care plan
- Frequent, tailored touches from Aspire’s care team based on the patient’s specific needs, including regular visits to the patient’s home or virtual touch points
- 24/7 support to patients
- The patient’s status, care plan and progress are tracked through a comprehensive information technology system that can produce a wide variety of reports for patients, caregivers, physicians and health plans
It is so helpful to be able to call when I need something or have a question. My fear factor drops way down. Your care has kept me out of the hospital.