Care Management Services

Comprehensive Care Management

xG Health’s care management services provide a wide range of services that include comprehensive high risk case and condition management activities, services, and interventions to manage diverse patient populations. Our care management services are based on Geisinger’s proven methods that have delivered strong results, both at Geisinger and at other provider systems with employed and independent physicians and leverage a wide array of skill sets to manage a broad population including commercial, medicare and Medicaid populations.

Our model of care management is data-driven, leveraging self-reported, claims and clinical data to segment patients, and identify specific and actionable opportunities designed for each segment. We also use data to monitor quality, utilization, and cost performance.

(CLICK HERE to learn more about our population health data analytics services).

We use Geisinger’s clinical experience to further stratify patients by clinician. Since data stratification cannot replace a care manager’s knowledge of the patient, our xG Health trained care managers use sound clinical judgment, taking into consideration the patient’s clinical assessment, health history, and psychosocial needs to determine the stratification of risk.

Our care management model provides specially trained and equipped case managers, health managers, and other allied health professionals. xG Health’s case and health managers are embedded in practices to focus on care management opportunities and intervention management. In addition, since the embedded model isn’t appropriate for all situations, we can provide remote and specialized case management services dependent on the population served  (i.e., pediatric, oncology, end-stage renal disease). We empower our care managers with care management software (Caristo™) and workflows to ensure delivery of reliable and reproducible results. The care management team brings the right approach to coordinate with other medical neighborhood providers. Most importantly, we leverage motivational interviewing and patient engagement strategies and tools to link with patients, their families, and caregivers.

xG Health deploys “boots on the ground” -expert care managers and trainers to help make your hospital system and practice sites as efficient and effective as possible.

Our care management services at a glance include:

  • Care management program design

    • Governance and structure

    • Care management workflow

    • Staff management and development

    • Tools to support implementation

  • Care management program implementation that lets you choose from various options:

    • Staffing Services. xG Health provides staffing services that includes case and health managers, Caristo™, and full care management program structure

    • Supervisory Services. xG Health provides a Care Management Supervisor, care management workflows, Caristo™

    • Training and Tools. We provide training and tools for your care management staff (care managers, leadership).

      • CLICK HERE to learn more about our unique adult learning  training services

      • CLICK HERE to learn more about our care management software – Caristo™

Transitions of Care. To help avoid re-hospitalization and to optimize care delivery through care continuum, we provide a solution for transitions of care. Using Geisinger’s techniques, the transitions of care solution provides comprehensive strategies that include a well-defined patient and provider discharge process, follow-up outreach, medication reconciliation, patient symptom monitoring plan, and an interdisciplinary care team approach.

Medical Neighborhood. A 360-degree view of patient care connects the advanced medical home with high-value specialty, ancillary, and community resources to optimize the plan of care for each patient. In addition, xG Health helps organizations understand the linkages between hospitals, primary care and post-acute providers across the continuum that are needed during transitions to ensure patient care is timely, coordinated and high quality and best organized to prevent re-admissions. The medical neighborhood helps you create relationships and opportunities to guide patients to the most efficient and effective providers. The xG Health solution helps you plan and build your medical neighborhood in steps, starting with an evaluation of potential partners and continuing through the development of relationships with other members of your medical neighborhood.

Managing populations is complex and hard work. Using xG Health’s collaborative, care-team model uncovers opportunities for maximum effect on population health. Our model has delivered strong results in reducing admissions and re-admissions and lowering the cost of care (CLICK HERE to see the results we achieved with our clients).