Evolution Health, an Envision Healthcare solution, is changing the way healthcare is delivered. Evolution Health is a care coordination and transitional care management solution that helps reduce gaps in care, enhance patient experience and improve overall financial performance.
We offer healthcare where and when patients need it using physician-led, interprofessional care teams who provide 24/7 clinical support.
Comprehensive Clinical Assessments
Evolution Health’s Comprehensive Clinical Assessments (CCAs), or Health Risk Assessments, capture patients’ disease state and psychosocial status. The CCA is an in-home or mobile, clinic-based assessment conducted by nurse practitioners, physician assistants or physicians.
Patients will receive a thorough face-to-face evaluation by a licensed clinician assessing the following areas:
- Current diagnoses
- Current medical providers
- History of physical health, symptoms and treatment including hospitalizations
- Medication review
- Review of biological, psychological, familial, social, environmental and developmental domains
- Risk assessment
- Treatment plan and treatment recommendations
Bridges patients between care settings by coordinating with primary care providers, hospitalists and specialists from hospital to home, hospital to skilled nursing facility, skilled nursing facility to home and/or hospital emergency department to home.
- Focus on evidence-based interventions delivered by interprofessional care team (mobile pharmacists, social workers, nurses, paramedics and community health workers)
- 24/7 support with rapid response capability to reduce preventable readmissions and preventable emergency department utilization
- Patient follow up for 30, 60 or 90 days depending on needs; patient transition back to primary care provider or specialist
- Hospital to Home
- Hospital to Skilled Nursing Facility (SNF)
- SNF to Home
- Emergency Department (ED) to Home
Longitudinal High Risk Management
Longitudinal High-Risk Management focuses on those patients who are at the highest risk for poor health outcomes. In the Medicare population, these patients are typically the costliest five percent and account for 39 percent of healthcare expenditures.
To proactively manage high-risk or high-cost patients, such as frail elderly, medically complex, mobility impaired or chronically ill, High-Risk Management features home and facility visits by primary care physicians or specialists. These high-risk patients become part of an Advanced Illness Management care model which provides comfortand coordinates care for patients with advanced chronic illness and functional decline as care needs shift from curative to palliative.
Advanced Illness Management
Provides comfort and coordinates care for patients with advanced chronic illnesses and functional decline as goals of care shift from curative to palliative. AIM focuses on providing relief from the symptoms, as well as, the physical and emotional stress experienced by patients with advanced chronic illnesses.
The ability to blend curative and palliative care that can be customized to the individual as their goals of care and needs are changing is what Advanced Illness Management does best. It is particularly well-suited to patients who desire to reduce unnecessary healthcare utilization with relation to medications, tests and hospitalizations.
Our Medical Command Centers (MCCs) coordinate pre-acute and acute care needs using mobile clinicians and telehealth capabilities with rapid response care teams delivered in-home or virtually.
Unplanned care begins with patients calling the Medical Command Clinical Practice. We evaluate patients’ needs and then initiate care coordination by the appropriate members of the interprofessional care team made up of physicians, advanced practice providers such as physician assistants and nurse practitioners, registered nurses, paramedics and community health workers.
This model allows for needs- and time-appropriate resource matching for unplanned care, whether it is an unexpected disruption in prescription medication availability or an acute change in the patient’s condition. Solutions include an immediate dispatch of EMS resources, urgent and non-urgent use of telemedicine, scheduled follow-up response or an appointment from a member of the Evolution Health Mobile Integrated Healthcare (MIH) team. Navigating patients to an appropriately matched resource, or navigating the resource to the patient, offers a more optimal alternative to Emergency Department utilization and enhances the experience of care delivered by the system.