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Meritage Care Management & Care Transitions Services

Meritage offers Care Management and Care Transititions Services to our patients and to health systems. Meritage uses “The Meritage Model” – a hybrid care management and care transitions model we have developed to ensure that patients are receiving the highest quality care across the entire care contiuum.

The Meritage Model

Leaving the hospital is a confusing time for patients and their families, and is exacerbated by medication adjustments, new treatment plans, and a need for increased support post-discharge. This confusion can lead to patients being out of compliance with their doctor’s orders, missing appointments, or unable to receive newly prescribed and medically necessary durable medical equipment (DME). Any of these are missed opportunities that Meritage can help with.

Care Transitions Coaching

Care Transitions Coaching was designed to manage transitions from inpatient to outpatient and/or skilled nursing facility sites of care. By doing this MMN can prevent avoidable readmissions, improve patient safety through medication reconciliation, and improve patient satisfaction by providing better communication and coordination.

Complex Care Management

Patients are referred into complex care management by their physician or via Meritage predictive analytics software. Meritage Complex Care Management generally focuses on patients with one or more chronic illnesses such Diabetes, Congestive Heart Failure, COPD (Chronic Obstructive Pulmonary Disease), and Coronary Artery Disease. Meritage also has programs for Behavioral Health and social support.

Care Coordination

Nurses and Patient Care Coordinators work as a team to identify barriers to healthcare and match patients with resources to overcome those barriers. Most importantly, Meritage provides patient centered care. The Nurses and Coordinators make sure that everyone involved in the patient’s care is well informed, especially the primary care physician, patient, and patient’s family. For both Complex Care Management and Care Transitions Coaching the nurses use a variety of tools to coordinate care, including a patient activation measure, medication reconciliation coaching, discussions about advance care planning, self-management coaching, patient/family safety education, and fall risk education.