Services

Contracted RN care-management support

Each area below is delivered within the RN scope of practice and according to your practice's policies, clinical workflows and applicable requirements. Support is scoped to your patient population before anything begins.

Chronic Care Management Support Transitions of Care RN Care Coordination Patient Navigation Community Resource Coordination

Chronic Care Management Support

RN support for patients with ongoing chronic-care needs, between the visits where most of the management actually happens.

Patients with multiple chronic conditions need contact more often than a practice schedule allows. Anu provides the RN capacity to make that contact happen on a predictable cadence, documented and reported back to your clinical team.

The practice sets the parameters. Anu does the outreach, keeps the record current, and escalates anything that needs a clinician's attention.

Support includes

Patient outreach on a schedule your practice sets
Care-plan support
Medication reconciliation and education
Monitoring and follow-up
Coordination with specialists and other providers
Identification of care gaps
Communication of clinical concerns to the practice
Ongoing care coordination and documentation support

Transitions of Care

Support for patients moving between settings — the window where follow-up is most likely to be missed.

A patient discharged from the hospital, the emergency department, skilled nursing or rehab arrives back in your practice's population with a changed medication list and a follow-up appointment somebody has to make sure happens.

Anu provides RN support through that window: timely outreach, medication reconciliation, and clear communication back to the practice so the follow-up visit is informed before the patient walks in.

Support includes

Outreach following hospital, ED, skilled nursing or rehab discharge
Medication reconciliation against the discharge summary
Support scheduling and preparing for primary-care follow-up
Coordination with the discharging facility where appropriate
Communication of concerns and changes to the practice's clinical team

RN Care Coordination

Ongoing coordination for the patients who need more support than a scheduled visit provides.

Every practice has a subset of patients who absorb a disproportionate share of staff time — the calls, the questions, the referrals that need chasing, the results that need explaining.

Anu takes on appropriate coordination work for those patients so that it happens consistently instead of whenever someone at the front desk finds a gap.

Support includes

Ongoing coordination between office visits
Referral and appointment coordination
Follow-up on outstanding items and results communication per practice protocol
Documentation support within the practice's workflow

Patient Navigation

Helping patients understand and move through the care your practice has already directed.

A plan the patient does not understand is a plan that does not get followed. Navigation support helps patients connect with the appropriate providers, services and resources your practice has identified for them.

This is education and coordination within the RN scope of practice — never independent diagnosis, and never a substitute for your clinical direction.

Support includes

Plain-language reinforcement of the practice's care plan
Help connecting with appropriate providers and services
Support preparing for specialist appointments
Identification of practical barriers and reporting them to the practice

Community Resource Coordination

Connecting patients with the community resources that affect whether a care plan is workable at all.

Transportation, food access, medication affordability and whether anyone is available to help at home determine outcomes as surely as the prescription does, and identifying them is rarely something a fifteen-minute visit can accommodate.

Where appropriate, Anu helps identify these barriers and connect patients with community resources, then reports what was found back to the practice.

Support includes

Identification of non-clinical barriers to the care plan
Connection to appropriate community resources
Follow-up on whether the connection was made
Reporting back to the practice's clinical team

Pricing

Scoped to your practice

Care-management support is customized to each practice’s patient population, workflow and RN support needs. Pricing is discussed directly with each practice.

Schedule a Practice Consultation

Anu Health and Wellness provides contracted RN care-management support to physician practices. Services are provided within the RN's scope of practice and according to the policies, clinical workflows and applicable requirements of the contracting practice.