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978-635-9090
Team Based Care
Supporting every Ibis Member is an informed care team that is ready to step in when a Member needs extra support.
Member Advocate
Coaching for best self-management habits at home.
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Through regular check-ins, Member Advocates support Ibis members in understanding their own health and improving self-management. Ibis notifies Member Advocates when members need help with staying on track with their care plan, or if they need help recovering from an episode of declining health. The Member Advocate is typically the first person to reach out to Ibis Members and is always a trusted partner. |
Nurses and Counselors
Triaging physical, mental and social health and initiating interventions.
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The Ibis Care Team includes nurses who monitor members' health and initiates clinical intervention when needed. Nurses are specialized in the signs and symptoms off deteriorating chronic conditions.The Ibis Care Team also includes counselors who monitor and triage mental health. Working under the guidance of the Chronic Care Specialist, the Ibis Care Team fosters a collaborative care model essential for maintaining chronic health. |
Chronic Care Specialist
Collaborates with PCP and specialists to oversee daily chronic care at home.
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The Chronic Care Specialist is typically a geriatrician who conducts chronic health assessments, develops person-centered care plans, provides immediate interventions in the event of chronic health exacerbation, and educates Member about better health management. Health assessments are shared with the PCP and other specialists and care plans are collaboratively changed to fill in any gaps in care identified through the Ibis program. |
A Virtual first, collaborative care model
The Ibis Chronic Care Specialist on one hand leads the Ibis Care Team in providing virtual, daily support for health management at home. On the other hand, the Chronic Care Specialist is a partner to a Member's PCP, fostering collaboration between all of the Member's facility based clinical and non-clinical care providers. The combination of the daily care planning done by the AI and the consultative expertise provided by the Chronic Care Specialist leads our health system towards the ideal of integrated care.
