Care Management: A Model of Equity

Our care management model is unlike that of most medical centers. That’s because our members typically face more barriers to healthcare than most people. Our job is to eliminate as many of those as possible.

Our members face the daily threat of housing and food insecurity, challenges with substance use and behavioral health, and chronic, clinically complex health conditions.

Restoring our members’ health and wellbeing means addressing their social, psychosocial, and physical needs in a compassionate way that’s free of judgment.

Surrounded by Care

Care in Our Centers

Core Team

• 2 Nurse Care Managers (RN)
• Behavioral Healthcare Manager (LSW)
• 2 Care Team Coordinators (MA)

Care in Our Centers and Community

Integrated Services

• Utilization and Transitional Care Management
• Post-Acute Care
• Behavioral Health Management, Counseling, and Substance Use Treatment
• Pharmacy and Medication Therapy Management
• Same-Day and Immediate Care
• Advanced Primary Care Treatment – Infusions
• Diagnostic Radiology and Labs
• Infectious Disease Management
• Member Funds and SDoH Programs
• Member Relations and Member Advisory Council

Care in the Community

Community Team

• Community Health Workers
• New Member Enrollment Specialists
• Transitional Care Managers (RN)
• Community-Based Medical Providers (NP)
• Community Nurse Care Manager (RN)
• Community Behavioral Healthcare Manager (LSW)
• Transportation Driver
• Provider Relations and Quality Team

Care that Adapts

Health accompanies us wherever we go, no matter how we’re feeling. And illness—whether chronic or acute, brief, or lengthy—is never convenient. That’s why it’s important for our care to go where it’s needed. Our care adapts to our members’ needs.

Complex Care

Some of our members need more care—whether medical, behavioral, or SDoH-related—than others. For those with unstable chronic or hard-to-treat illnesses, we assign a complex care manager—either an RN or LSW—and establish custom care programs with goals based on the key driver of their health instability.

Community Care

Some members need care to meet them where they are, to be portable, delivered directly to their homes. Our community team, composed of RNs, LSWs, advanced practice nurses, and community health workers, serves as a liaison between our PCP and community members who need care outside of the office.

Transitional Care

For members in the hospital, our transitional care managers coordinate discharge planning and care, with an eye toward reducing readmission. We work directly with facility staff to build post-discharge care plans—medical, behavioral, or SDoH—and coordinate follow-up visits and home nursing or therapy needs.

Latin American senior woman getting a COVID-19 vaccine by a doctor at a nursing home

The AbsoluteCare PCP

Our members have a more personal—and personalized—experience. That’s because our six-member pod serves a small member panel, with fewer than 12 visits per provider, per day.

We take the time to hear each member’s story, to learn what has happened to them, and to begin earning each member’s trust. Same-day and walk-in appointments enhance that trust.

Each member is assigned a primary point of contact (Care Team Coordinator, Nurse, or Behavioral Healthcare Manager), who handles all member questions, triages their needs, and coordinates care. The primary point of contact advocates on behalf of the member and assists with medical, behavioral, and social issues. Through regular contact, even between visits, we can build and maintain trusting, therapeutic relationships.