Intercede Health’s Transitional Care Centers offer an innovative outpatient care option for high-risk and medically-complex patients. These specialized outpatient clinics provide short-term, focused care in order to optimize treatment plans and to teach patients how to self-manage their conditions.

Benefits
Intercede Health Transitional Care Center patients benefit from:

• Unlimited Center visits (as medically appropriate)
• Direct telephone access to a Center physician 24 hours a day, 7 days a week
• Health Risk Assessments
• Screening for depression and other conditions
• Personalized care plans developed from evidence-based protocols
• Help coordinating services like labs and other tests
• Reminders for preventive testing and appointments
• Self-monitoring tools and equipment
• Education materials
• Self-management training

How They Work
Intercede Health Transitional Care Centers are designed to care for the 5% of patients who typically account for more than 50% of all healthcare costs. Potential patients for the program are identified through health plan claims data, primary care physician referrals, and referrals from other disease management programs (like Telephonic Disease Management).

Patients accepted into the Center program first undergo a thorough initial exam, including a review of medications and past medical history. Intercede Health staffs its Centers with expert physicians who have specialized training in managing medically complex patients. Using evidence-based guidelines, Center physicians develop streamlined, coordinated care plans that take all of a patient’s conditions into account. Patients and their primary care physicians are encouraged to participate in treatment decisions.

After the initial exam, patients continue to go to the Center for continued monitoring and self-care education. Patients may see the Center physician or a Center nurse. The frequency of follow-up visits depends on the patient’s risk level. Many Intercede Health Center patients have weekly visits for the first month of treatment! Telephonic Disease Management maximizes therapy and is usually a part of Intercede Health Center programs.

The average patient spends 6 months assigned to a Center. Upon stabilization or achievement of treatment goals, patients transfer back to their primary care physician for regular care. Intercede Health Center physicians do not replace a patient’s primary care physician. Instead, they partner with primary care physicians in order to provide a more intense level of service than can be provided in a regular PCP office. Primary care physicians receive typed reports of each office visit and are encouraged to participate in patient care.