Health Plans
Your members with complex care needs prefer home-centered care
Reduce high-cost utilization of the ER & hospital
Patients with polychronic conditions drive your highest costs. Six in ten Americans live with at least one chronic disease, and four have two or more. Most see their primary care doctor once a year – on average for 18 minutes.
According to studies, Medicare beneficiaries with one to four chronic conditions have the highest risk for emergency department visits and admissions.
The Spiras Care nurse develops a trusted patient relationship to provide individualized, home-based, whole-person care for Chronic Heart Failure, Diabetes, COPD, Hypertension, and other conditions. The Spiras Care nurse becomes a clinical family member and advocate through their trusted patient relationship.
As a result of Spiras Health’s 8 years of care-at-home, we increase patients’ access to care, improve self-care, educate for empowerment, enhance the patient and provider relationship, and keep your members out of the hospital.
Nurse practitioner-driven care
Our experienced team of nurse practitioners and nurses deliver in-home and technology-enabled care augmented with 24/7 access and remote monitoring.
Collaboration with providers
We minimize provider abrasion with your network physicians by keeping them abreast of the patient’s condition, including follow-up notes, updated care plans, and medication changes through provider-to-provider consultation.
Medication adherence
Spiras Health clinicians review a patient’s current medication, monitor any changes, and educate them on how and when to take medications. We address refills and measure ongoing improvement while encouraging patient compliance. Download our Outcomes to learn more.
Social Determinants of Health
Spiras Health clinicians observe the patient’s home environment and complete assessments of health-related social needs. We refer patients to appropriate plan or Spiras Health resources, confirm closure on the issue, and document which resource was used to address the need. Spiras provides SDoH data to our plan partners using Z-codes in encounter files.
Spiras Health delivers measurable outcomes
34%
Patient Engagement
24%
Hospital Admission Reduction
28%
ER Usage Reduction
95.7%
SDoH Gap Closure rate
92%
Improvement in Medication Adherence (after 180 days)
Home-Centered Clinical Model
When members understand their conditions, understand how to adopt healthier behaviors, and learn to recognize when symptoms worsen, they become better at self-management.
Our clinicians develop a relationship with each patient. This enables our nurses to discover personal barriers and motivators and create a patient-centered care plan that reflects the patient’s goals.
The longitudinal and relationship-based nature of our program ensures that patients experience a personalized approach to developing and achieving their care plan goals to improve their well-being.
Regular in-home visits are scheduled and nurses call between visits to check in on their patients. Easy texting between patients and their nurse provides secure, convenient access to a clinician.
If a condition worsens, our patients know how to contact their Spiras Health clinician, who can assess their needs, provide treatment, or recommend an immediate course of action.
Transition of Care
Spiras Care clinicians assess patient needs post-discharge and review discharge instructions with the patient to answer questions ensure understanding.
A licensed provider reconciles medication and educates the patient on any changes.
Clinicians confirm or arrange a follow-up PCP visit and coordinate needed follow-up care to ensure care is set up for recovery and helps prevent unnecessary readmissions.
Cost-Efficient Team Approach
Our scalable, community-based teams deliver highly responsive in-home and telephonic care for small patient panels.
These field teams are overseen by Nurse Practitioners who provide guided video visits with patients. Medical Directors oversee Nurse Practitioners and round with them regularly.
Active Engagement
Our proprietary, predictive model identifies patients with complex chronic conditions likely to have avoidable spend.
Our seasoned enrollment team contacts patients to schedule an initial visit with a Spiras Care field clinician.
Provider Collaboration
Our patients often see multiple physicians and struggle to understand their conditions, care plans, and medications.
We answer questions patients may have post-visit or in between their doctor visits.
We help manage their conditions, communicate changes with their physicians, coordinate tests, access their appointments, discuss medication needs, and share notes.
We also encourage patients to adhere to their doctor visits and care plans.
Enhanced Patient Experience
Because of our home-centered approach, we build close, trusted relationships.
Our five-star member experience makes patients feel connected and supported, knowing that our Clinical Care Team is available by phone 24 hours a day, seven days a week.
SDoH Reporting
Our Patient Advocate team helps match assessed needs with the right resource to meet those needs. We tap into plan resources, such as Find Help, and identify hyper-local resources to solve specific needs.
Our structured workflows ensure a documented, systematic approach to resolving health related social needs that includes patient confirmation that their needs are met.
Focusing on Health Equity and the Patient Experience to Improve Medicare Star Ratings
Deliver an innovative care model built to transform the member’s care experience
Read the Blog Post
The Spiras Health Patient Journey
With frequent and measured touchpoints that are responsive to a member’s changing acuity level and personal preferences, Spiras provides ongoing care, including acute visits, 24/7 availability, remote monitoring when needed, and transitional care support.
Our care supports the whole person, focusing on their conditions and helping them engage more deeply with their own healthcare needs.
Member Engagement
Our engagement team reaches out to prospective members by phone, letter, or text.
Our team collaborates with health plan partners to co-brand and align messaging of ongoing member communications.
Regular reporting keeps clients up to date on enrollment rates and enables collaboration on approaches to further increase enrollment.
Initial In-home Visit
Our community-based clinician visits members to review their medical conditions, medications, and social/environmental needs. The clinician provides clinical education and motivational support to the patient and engages available caregivers.
A Nurse Practitioner connects with a video visit to assess clinical and medication needs and coordinate with the patient’s PCP/specialist.
Telephonic pre-visit assessments may be conducted to gather history and begin assessment of needs.
Regular Telephonic Visits
Scheduled phone calls between home visits identify and document symptoms, medication adherence, physician visits, ER use, and any admissions.
Every call provides patient education and motivation.
Scheduled Follow-Up Home Visits
Our home-centered approach helps us stay on top of changes, address medication issues, assess needs, provide acute care, and arrange referrals for emerging needs.
Our face-to-face approach builds trust, reveals underlying issues that hinder healthier living, and supports patients in meeting their care plan goals.
End-of-Life Planning
The trusted relationships developed between the Spiras Care clinical team and our patients allow us to discuss palliative care or hospice needs.
Our clinicians are trained to discuss these highly personal needs and engage the patient.
Spiras Health delivers high satisfaction
95%
Member Loyalty
Patients reported being “highly likely” to re-enroll with their health plan due to care from Spiras Health
95%
Patient Experience
Patients rated Spiras Health “10 out of 10” on their experience with clinicians
Implementing our care-at-home program
Spiras Health works collaboratively with our health plan partners to implement our solution, concentrating on the individual features of each health plan. Our proven approach includes:
Contract Execution
Implementation begins with a finalized Statement of Work and contract.
Credentialing
Provider credentialing aligns with the go-live date.
Project Planning
We create a customized implementation plan based on the health plan’s needs.
Data Share
We establish HIPAA-compliant data-sharing processes.
Reporting
The program’s performance is measured through mutually agreed reporting.
Engagement & Communications
Preferred messaging and engagement methods for members and providers are established.
Commonly Asked Questions
Need more information? Reach out to us at 855-638-9596.
How does Spiras Health deliver value-based care?
Spiras Health’s risk-based provider-driven care model is based on medical cost reduction, quality improvement, improved patient experience and satisfaction, and better patient health outcomes.
Our approach includes:
- Identifying and stratifying patients with avoidable spend,
- Delivering a comprehensive in-home solution to improve health and avoid ER and inpatient visits,
- Addressing social and behavioral care needs.
How does Spiras Health’s care-at-home differ from conventional home health care services?
We offer a longitudinal care model that identifies and manages complex patient populations and delivers holistic, whole-person care month after month.
This model serves patients beyond episodic needs, primary care, or simple evaluations.
As a value-based care provider, we can support underserved populations, rural markets, and members not attributed to VBC providers.
How does Spiras Health coordinate with the PCP/Specialist?
Spiras Health Nurse Practitioners collaborate with providers to serve as an extension of their practice and to minimize provider abrasion.
This includes:
- Ensuring patients comply with physician appointments,
- Engaging providers regarding patient condition changes, medication needs, or requested labs or tests,
- Keeping providers in the loop with documentation and notes regarding patient status.
How do Spiras Health Nurse Practitioners work with a plan’s care management team?
Spiras Health clinicians develop a collaboration plan with a health plan’s care management team to establish a meeting cadence and ensure ongoing coordination on critical patient activity.
This includes:
- Sharing visit notes via a secure portal,
- Tracking and reporting on completed SDoH pathways,
- Making referrals to network medical and behavioral health providers,
- Supporting interoperability between the plan and Spiras Health for data exchanges related to gaps in care and visit notes.
How does Spiras Health address social needs?
Our presence in the home allows Spiras Health clinicians to observe the patient’s environment and assess health-related social needs.
We utilize health plan resources and augment them with local services in the patient’s community.
Our structured workflows ensure that social needs are met from the patient’s perspective.
How does Spiras Health care for rural populations?
Underserved rural populations benefit from expanded access to our clinicians.
We achieve this by:
- Adjusting clinical service areas to accommodate driving distances.
- Deploying multi-modal visit options and the right balance of in-person and telehealth services.
- Hiring a local care team with knowledge of rural nuances and SDoH resources.
- Approaching patients longitudinally and managing patient load per clinician to create more time for patient care.
What government lines of business does Spiras Health work with?
We work with Medicare Advantage, Managed Medicaid, and D-SNP Plans.
We target the most vulnerable patients with an elevated probability of avoidable costs.
Main Phone
855-638-9596
Address
111 Westwood Pl
Suite 100
Brentwood TN 37027
Want to learn more about Spiras Health?
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