Senscio Health Centers for Personalized Care
To meet the healthcare needs of patients with complex health requires compassionate human touch, supported by data and knowledge.
The Ibis solution is unique in the way we leverage powerful insights derived from data gathered daily from the home with relationship-based coaching and care through our Centers for Personalized Care (CPCs)
Each member whose health we help manage is matched with a CPC coach who delivers all of the following services:
Each dedicated coach is also deeply involved in supporting self-management to the level of a member’s capabilities, thus building self-confidence and personal well-being. The coach engages the member when the Ibis platform recognizes a decline in health, prompting for additional self-management actions to be taken as dictated by protocols designed by the member’s clinicians. If health continues to decline, the coach will communicate with the responsible clinician for timely fact-based diagnosis and therapy adjustments. This results in exacerbations being treated in the home or in the clinicians office, avoiding unnecessary hospitalizations.
The Ibis solution is unique in the way we leverage powerful insights derived from data gathered daily from the home with relationship-based coaching and care through our Centers for Personalized Care (CPCs)
Each member whose health we help manage is matched with a CPC coach who delivers all of the following services:
- Personalized care plan creation and updates
- Installation and training to use the Ibis platform
- Coaching to support self-management needs
- Rapid follow up with member and clinician when health status changes as recognized by the Ibis AI engine
- Coordinating proactive interventions to mitigate health risks recognized by Ibis
Each dedicated coach is also deeply involved in supporting self-management to the level of a member’s capabilities, thus building self-confidence and personal well-being. The coach engages the member when the Ibis platform recognizes a decline in health, prompting for additional self-management actions to be taken as dictated by protocols designed by the member’s clinicians. If health continues to decline, the coach will communicate with the responsible clinician for timely fact-based diagnosis and therapy adjustments. This results in exacerbations being treated in the home or in the clinicians office, avoiding unnecessary hospitalizations.
Proactive Clinical Interventions
The key to our success in attaining quadruple AIM results is the timely follow-up by the coach when changes in health status are detected by the Ibis platform. Examples of changes is health status include:
Ibis integrates and interprets data from multiple sources to recognize these worrisome changes to health status. Once recognized, Ibis prompts the member and their CPC care team for self-management needed to address change in health status. The care coach further engages with self-management support while connecting with the clinician to intervene as required.
- Early symptoms of COPD exacerbations
- Warning signs of fluid retention due to congestive heart failure (CHF)
- Hypoglycemic and hyperglycemic events
- Episodic hypertension
- Onset of depression
- High risk for falls
Ibis integrates and interprets data from multiple sources to recognize these worrisome changes to health status. Once recognized, Ibis prompts the member and their CPC care team for self-management needed to address change in health status. The care coach further engages with self-management support while connecting with the clinician to intervene as required.
Proactive Interventions to Improve Self-Management
Since self-management is the biggest driver of health outcomes, personalized care coaches engage members whenever gaps in self-management emerge, to keep them on-track. Example of events which will stimulate coaching interventions include:
- Lifesaving medications are missed
- Poor dietary practices
- Symptoms are not being monitored
- Too sedentary a lifestyle
- Medications are not refilled
- Doctors appointments are missed
- Activities of daily living are skipped
- Changes in sleep patterns
- Changes in activity level
