How we do it
Netrin Health provides wrap-around services to support providers and patients 24/7 through our team of people, processes, and tools. We begin with a one-on-one conversation to identify your practice priorities and meet with you to develop an individualized plan of how to accomplish your practice goals.
Interdisciplinary Care Management
Bringing care beyond the office visit
Care management is a patient-centered, health care intervention that involves regularly scheduled, proactive outreach to patients beyond their traditional doctor visits. Care management can improve patient outcomes and reduce their need for medical services by increasing coordination of care across different care settings, eliminating duplicated services, and empowering patients and their caregivers to meet their health goals.
Netrin Health care managers develop personalized, longitudinal care plans based on the patients’ overall health and functionality, social needs, and known medical conditions and schedule regular, one-on-one encounters with the patient to monitor and support their progress. Our team of care managers include nurses, community health workers, health coaches, and pharmacists so that your patient’s holistic needs are met.
Annual Wellness Visit
Attributing more Medicare patients
Success in the value-based world starts with the annual wellness visit, which focuses on preventive care, screenings, and quality measures. Importantly, the annual wellness visit is what Medicare uses to attribute a patient to a provider. Netrin Health care managers ensure Medicare patients schedule and complete their annual wellness visit with their primary care physician. Our data analytics provides us up-to-date lists so that your patients do not miss a visit, and we help optimize your practice workflow based on your individual needs.
Making access to health care convenient
Telemedicine supports long-distance doctor visits for patients with acute and chronic health care needs using telephone or video conferencing. Netrin Health is ahead of the curve in telemedicine integration and has partnered with doxy.me, an easy-to-use HIPAA-compliant solution that requires no downloads for patients or practitioners. One click allows the patient to enter the exam room. With this telemedicine solution, our practices maintain office-visit volumes during crucial times and our patients have reliable and convenient access to care without complicated technology.
Chronic Care Management
Lowering the costs of health care
Nearly 8 in 10 older adults have one or more chronic conditions, such as high blood pressure, obesity, diabetes, or heart failure. People with multiple chronic conditions spend more money on doctor visits and medications and are more likely to go to the emergency room or be admitted to the hospital.
It doesn’t have to be that way. People who learn how to manage their conditions can improve their quality of life and reduce their health care costs. That’s where chronic care management comes in. Netrin Health care managers create care plans specifically for patients with chronic diseases to help them avoid complications, reduce unnecessary hospital utilization, and prevent hospital readmissions.
Transition Care Management
Reducing hospital readmissions
Transition care management (TCM) facilitates the successful transition of a patient from a hospital, nursing home, or rehabilitation center back to their home. Through TCM, care managers ensure that a discharged or transitioned patient schedules an in-person visit with their physician within 48 hours to one week after discharge. Effective transitions in care help reduce care gaps and readmission rates. Netrin Health trains providers to integrate care-transition workflows into their practice and help provide personalized transition care plans, particularly for patients who are high utilizers of hospital care.
Remote Patient Monitoring (RPM)
Integrating real-time patient data
Remote patient monitoring (RPM) supports health care delivery where people live. Combining advances in health information technology and increasing availability of connected health and medical devices, RPM continuously gathers patient data in real-time—in between scheduled doctor visits. The result is a more complete picture of a patient’s health.
The goals of RPM are to inform care management and to reduce the need for inpatient or emergency care. Netrin Health is organizing the resources, technology, and expertise to provide RPM to independent provider practices for a variety of conditions.
Promoting patient adherence
Comprehensive medication management can help increase patient adherence and reduce adverse drug-related side effects in multiple chronic diseases. When adherence increases and side effects decrease, health care utilization and health care costs also decrease and patient satisfaction increases. Netrin Health pharmacy integration includes individual patient assessments of their medications and personal goals and needs regarding their medication plan as well as education on how to take their medication safely and effectively.
Behavioral Health Integration (BHI)
Connecting mind and body
Across the country, 60% of adults with mental illness don’t receive essential behavioral health care. Providing behavioral health care is important because mental health and substance use disorders typically coincide with and worsen other chronic conditions and contribute to avoidable ED and hospital utilization as well as increased mortality.
Integrating behavioral health care in primary care overcomes barriers to care and lowers health care costs while also improving patient outcomes. In the primary care setting, BHI commonly focuses on depression, anxiety, alcohol use disorder, and opioid use disorder.
Netrin Health has the expertise and connections to guide primary care practices to integrate the behavioral health model that best fits their patients’ needs. Whether you want to add a therapist in office or build a collaborative relationship with a psychiatrist off-site, Netrin Health will help meet the needs of your patients.