Continuity

With a Continuity Membership you have the opportunity to get established with St. Luke’s At Home – Specialized/Enhanced Primary Care for the Older Adult.

St. Luke’s At Home is coordinated, continuous, primary care across settings and transitions including, hospital, rehabilitation, assisted living and nursing home.

St Luke’s At Home provides:

• Primary Care (Internal Medicine)
• Appointments that are not rushed. Communication and education are an integral part of care.
• Patient participation as fully informed and engaged partners in their health needs and goals.
• Specialty services such as bone health, diabetes care, chronic and medically complex disease management.
• Medical visit flexibility and access – traditional office, telehealth, in home (for qualified patients), and hospital care.
• User friendly medical innovation and technology.

St. Luke’s At Home utilizes Remote Physiologic Monitoring by providing patients in their home with devices such as digital blood pressure cuffs, blood glucose monitors, scales, pulse oximeters and thermometers that transmit data wirelessly to your provider.

Providing access to real time data allows for the patients and physicians to identify and intervene when closely monitoring chronic conditions.

If you have two or more chronic illnesses (such as but not limited to diabetes, hypertension, arthritis, COPD, hyperlipidemia, autoimmune disease, osteoporosis, depression, heart disease, dementia ) OR you have a single complex/serious condition, you qualify for a program that is covered under Medicare which provides monitoring and coordination to reduce risk of hospitalization or worsening of your condition.

With your physician as the lead, your CCM Nurse will develop a comprehensive care plan to address your medical needs, with a problem list, detailed interventions, and measurable and attainable goals. Care Management for chronic conditions includes – frequent assessment of patient’s medical, functional, and psychosocial needs; approaches to ensure timely receipt of recommended preventive care; medical service coordination and monitoring; medication reconciliation, review of adherence, and potential interactions; and oversight of patient self management and symptom management.

Your CCM Nurse is available M-F. Even if you do not call, your nurse will be sure to call you or your family/caregiver every month to monitor your health and progress. CCM is initiated after patient consent. Medicare/Medicare Advantage Plan is billed monthly for this service and is covered in full (after your Part B deductible) except for an amount under $10 that is generally covered by a Medicare Supplement.

To learn more about Medicare Chronic Care Management click here.

Membership fee may be billed as pre-pay monthly or quarterly.

Insurance does not cover membership fee or Aging Life Care Services.

Insurance does cover physician visits, Medicare Chronic Care Management and Remote Physiologic Monitoring.

St. Luke’s At Home files patient insurance claims. Providers are credentialed/participate with all Medicare, secondary and NC commercial plans.