Evaluation of Intensive Management Patient Aligned Care Team

"The ImPACT team offers the following services:~* An intensive intake process, including a home visit if deemed appropriate~* Frequent contact (in-person, telephone, or secure messaging) tailored to a patient's needs~* After-hours access to on-call team member in order to avoid unnecessary emergency care~* Optimization of chronic condition management using evidence-based protocols~* Navigation of transitions between hospital and home~* Coordination of specialty care, including contact with specialists when indicated~* Rapid response to signs of health status deterioration or other stressful events~* Assess patient goals, advance directives, Physician Orders for Life-Sustaining Treatment"