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Proactive Health CareManagement

Proactive Health Care Management

Clinical Services

Nurse practitioner services for post-acute care, from the transition out of the hospital through skilled nursing and discharge planning.

On-Site APRN Visits

Licensed APRNs caring for patients directly within your facility.

  • Face-to-face clinical assessments and treatment
  • Acute and chronic condition management
  • Coordination with facility nursing and therapy teams
  • Clinical input for treatment and escalation decisions

Wound Care

Wound assessment, treatment, and prevention support for complex post-acute populations.

  • Comprehensive wound evaluation and staging
  • Treatment plans based on clinical assessment
  • Pressure injury prevention strategies
  • Staff education on wound management standards

Chronic Disease & Medication Management

Proactive management of complex chronic conditions with careful medication reconciliation and monitoring.

  • Diabetes, CHF, COPD, and hypertension management
  • Medication review and deprescribing when appropriate
  • Symptom monitoring and care plan adjustments
  • Review for medication risks and adverse effects

Transitional Care (Hospital-to-SNF)

Coordinated care after hospital discharge, with attention to medication reconciliation, follow-up needs, and clinical changes.

  • Timely post-admission assessments
  • Medication reconciliation at transition
  • Communication with hospital discharge teams
  • Early identification of clinical deterioration

Palliative Care

Comfort-focused care for residents with serious illness, emphasizing quality of life and goals of care.

  • Goals-of-care and advance care planning
  • Symptom management and pain control
  • Family education and support
  • Interdisciplinary palliative consults

Quality Review Support

Quality review support shaped around facility-selected priorities and available information.

  • Review of facility-selected measures
  • Discussion of clinical patterns
  • Support for documented action plans
  • Coordination with facility leadership

Staff Education & Training

Clinical education that gives facility teams practical guidance for safer resident care.

  • On-site clinical in-services
  • Disease-specific education modules
  • Topics selected with nursing leadership
  • Skills reinforcement for nursing staff

Chart Review & Written Follow-Up

Provider-led chart review with written follow-up for the scope agreed with the facility.

  • Medication and polypharmacy review
  • Review of selected high-risk cases
  • Written findings for the agreed review
  • Follow-up discussion with facility leadership

Acute Change in Condition Evaluation

Clinical evaluation when residents experience a sudden change, supporting timely treatment and escalation decisions.

  • Evaluation according to the agreed coverage plan
  • Treatment initiation within the facility
  • Physician and family communication
  • Documentation for continuity of care

Support beyond the visit

Chart review, coverage options, and nursing education are discussed with each facility. Only the services included in the agreed scope apply.

Chart and medication review

Provider-led chart reviews may include medication and polypharmacy review, with written follow-up for the agreed scope.

Coverage planning

On-call, weekend, and telemedicine options are discussed with each facility and apply only when included in the agreed coverage plan.

Nursing education

Clinical in-services and one-to-one education can be discussed based on the needs of the nursing team.

Long-term care experience

Providers bring experience from staff and management roles in long-term care and skilled nursing.

A practical next step

Let's talk about your facility's clinical priorities.

Share your setting, coverage needs, and goals. We'll use the first conversation to determine whether there is a strong fit.