Advocated for VA benefits
Provided transportation assistance
Coordinated home medical devices
End of life care coordination
Whether you call them frequent fliers, super-utilizers or high-risk members our patients are trying to do the best they can. Sometimes they just need to be pointed in the right direction and other times they need intense case management. In either case, we’ll be there for them until they get the support they need.
Complex, vulnerable patients
We currently serve patients in Allegheny County, Pennsylvania. Our only inclusion criteria are that the patient live in Allegheny County and that the the patient is “vulnerable,” however the person making the referral determines vulnerability. Here’s the most recent snapshot of our vulnerable patients.
- Average Age is 64.4 years
- They have 3 chronic illnesses each
- 54% also have at least one mental health diagnoses
- 42% live alone
- On average, in the year prior to engaging with our team, our patients had:
- 7 ED visits
- 5 hospital admissions