SUPPORTIVE CARE SERVICES OF MICHIGAN INC

Programs: With a culturally sensitive interdisciplinary team of professionals, the at home support program provides individualized care to chronically ill patients and their family caregivers. In an effort to reduce health care expenses and enhance the quality of life of both patients and family caregivers, at home support utilizes home based condition management to provide clinical education, consumer advocacy, and assistance with health care system navigation. At home support services consist of home visits and individualized treatment plans by a nurse and counselor with the aide of patient family assistants and volunteers. At home support works closely with primary care physicians to relieve symptoms of pain, coordinate care, assist with treatment decisions, and provide a support system to caregivers. Available 24 hours a day, 7 days a week, the at home support team includes a doctor that specializes in recommending medications or treatments to relieve pain and symptoms caused by illness, nurses with advanced training in chronic illness and home based care, a counselor that assists in addressing interpersonal issues and lifestyle changes and assists with coordinating community resources, and patient family assistants that assist with personal care and providing support to caregivers. By developing partnerships with health care partners, at home support strives to create a service model that is outcome driven and that can flex to meet individual contracts. At home support also focuses on the development of new services for the future needs of patients and families with advanced chronic illnesses. For the year ending december 31, 2014, at home support provided $23,421 in charity care. The passage of the affordable care act brought new opportunities for health care providers to use innovation to enhance the quality of care while reducing the cost. In 2014, hospice of michigan (hom) and the detroit medical center (dmc) continued its partnership through its michigan pioneer aco, serving close to 350 patients per day. In addition to the dmc partnership, at home support was able to add expand enrollments between the three commercial payer partners bringing the patients being served to 812 by the end of 2014. By the continued collaboration with at home support, the michigan pioneer aco met one of the first goals of the centers for medicare medicaid innovation (cmmi) for these programs - "to rapidly demonstrate what can be achieved when highly coordinated care is provided to medicare fee-for-service beneficiaries. " partnered with first outstate partner in ohio and started orienting and training their staff in order to roll out and go live in the first quarter of 2014. At home support provides daytime triaging of calls and any after hours calls while the partner organization provides the field visits. At home support also provides all the data analytics and outcome reporting as well.