The Inbound Care Model
Enrollment
Powered by our AI-driven analytics, our staff identify those patients who have a high enough severity of illness and medical complexity to require facility-level care, but a functional and environmental status that could allow them to receive this level of care in their home.
Our embedded hospital liaisons and senior medical team work with the health system’s attending physician and discharge planning teams along with the patient and family members to validate that going home with Inbound is the right care plan.
Once a discharge order is placed, our teams plan all aspects of the home-based episodes. In coordination with the patient’s care team and family, we schedule all in-home and virtual visits, arrange for consults with the health system’s specialty physicians, codify the 24/7 oversight protocols into our proprietary workflow platform, and coordinate wrap-around services with our custom-curated partners.
Set-up
Our clinician meets the patient at their home to ensure they are stable and comfortable, then set up the technology and equipment that connects the patient to their virtual care team around the clock.
Next, the patient has their initial visit with a virtual rounding provider, who creates a plan for care episode. The provider arranges for everything the patient may need in their home during their stay, from at-home nursing care and therapy, imaging, labs, durable medical equipment, and more.
Care Episode
We coordinate the care team comprised of caregivers from the local health system, local and national supply chain partners, and Inbound Health to work together in providing world-class, comprehensive care both virtually and at the home.
Personalized care plans may include in-person nursing and therapy visits, daily virtual visits with our hospitalists and SNFists, mobile labs and imaging, home-based equipment, medication consultation and administration, non-emergency transportation, and more. All the while, the patient is monitored 24/7 by our clinical command center leveraging biometrics and digital surveillance coming from our proprietary digital engagement platform.
Throughout their stay, the clinical care team is just one click away. Our team leverages predictive analytics to ensure the patient’s care journey is customized to meet the patient’s medical and functional complexity. If a problem or need arises, our high-touch model allows for instant digital or in-person engagement and teams are rapidly deployed to the patient as necessary.
Ramp Down
When clinically appropriate, the Inbound Health team works with the care partners to ensure a safe and coordinated offramp process from high acuity home care that delivers the patient back into the health system’s network.
We schedule the appropriate follow-up visits and care administration to ensure that there is nothing dropped during the transition. We coordinate with the health system’s primary and specialty care network and associated care managers to ensure everyone is on the same page.
Following the acute episode, we remotely monitor the patient for the remainder of the thirty-day episode if needed, and ensure that our team is ready to react to any new patient or family member need. Finally, we coordinate the removal of any equipment from the family’s home and help guide the patient’s transition to the next stage in their care journey.
