PRIMARY CARE

Our Approach

The Important Role of a PCP

Our focus is in value-based care, taking FFS (Fee-For-Service) out of the equation. True patient-centered care shouldn’t focus on bill codes, but rather in understanding the “whole patient”, inclusive of the medical, environmental and social determinants to provide a level of care focused on each individuals’ desired quality of life.

As a result of our success in this model of care, we are the provider of choice for several PACE clinics (Programs for the All-Inclusive Care of the Elderly) throughout California.

PACE

As the contracted medical group for InnovAge, California’s largest PACE provider, our Physicians and Nurse Practitioners play an integral role within an eleven member interdisciplinary team built to wrap services around our participants. The PACE (Program of All-Inclusive Care for the Elderly) model of care provides a comprehensive medical/social service delivery system using an interdisciplinary team approach within a PACE Center that provides and coordinates all needed preventive, primary, acute and long-term care services. Services are provided to older adults who would otherwise reside in nursing facilities. The PACE model affords eligible individuals to remain independent and in their homes for as long as possible.

Quality Care Driven Through Patient Outcomes

Our Primary Care Physicians and Nurse Practioners “Quarterback” an impressive clinical and social supportive multidisciplinary team to guide the patient’s care, by creating a comprehensive approach for each complex patient’s needs
Providers navigate routine care and are the point providers for all specialty care and consults must run through their oversight to assure care continuity
When hospitalized, patients rely on our providers to navigate their care to a successful discharge home, or “the place” they call home
Our providers measure quality care first with cost effective medicine to not over utilize unnecessary and nonbeneficial services
Critical to success is the provider’s focus on guiding all medication administration and patient feedback

Each year we work in conjunction with our PACE partners and develop a Quality Assessment and Performance Improvement (QAPI) plan to meet the requirements of the State and Federal participation Guidelines
Our Group monitors performance against measures such as use of services, satisfaction, assessment data, and the safety and effectiveness of all services delivered to participants
We identify initiatives, set goals, measure baseline performance, and monitor progress. These objectives are tracked on a bi-annual basis, and are shared throughout the year