7. Correlation to Unbalanced use of HCBS Resources Independent Living Systems, LLC, All Rights Reserved.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18. PASS ™ Fully Integrated Care Transition Independent Living Systems, LLC, All Rights Reserved. Nutrition Management Medication Management Personal Health Record PCP & Specialist Physician Follow Up Red Flags / Signs & Symptoms Inpatient (Acute/Sub-Acute) Admissions: Nutrition Management Medication Management Personal Health Record PCP & Specialist Physician Follow Up Red Flags / Signs & Symptoms Post Discharge - Home (48-72 hrs): Nutrition Management Medication Management Personal Health Record PCP & Specialist Physician Follow Up Red Flags / Signs & Symptoms Follow-up Calls 2, 7, 14, 30 days Post Discharge: PASS ™ Coach & Care Support Representatives Referrals to Community Resources
19.
20.
21.
22.
23.
24.
25. PASS ™ “Best Case” Implementation Client 1: 500 Bed Private Hospital & Physician Practices Client 2: 1000 MA MSO & Medical Center (At Risk) Client 3: 2000 MA Member Health Plan (County Coverage) Admits to Hospital Pilot to manage specific MC admits based on Dx, & previous case management Manage admits for designated Dx to designated hospitals Manage admits for designated Dx to all hospitals in the County Independent Living Systems, LLC, All Rights Reserved.