Chronic & Transitional Care Management with Keystone Connect

Our Keystone Connect program is the support for both patient comfort and medical needs. With chronic care managers providing weekly contact (either with a visit or a telephone call), patients and their families can rest assured knowing conditions are being monitored and addressed.

chronic illness dementia

Keystone Connect is available to many residents in the Treasure Valley. For insurance to cover these services, patients must have multiple (two or more) chronic conditions that are expected to last at least 12 months.
Examples of chronic conditions include, but are not limited to, the following:
  • Alzheimer's disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Cancer
  • Cardiovascular Disease
  • Chronic Obstructive Pulmonary Disease
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases such as HIV/AIDS
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
  • The need for Establishment and ongoing revision of a comprehensive care plan

Comprehensive Care Plans

Comprehensive Care Plans are created to meet the unique needs of each house call patient. No two plans look exactly the same, but most consist of identifying problems, expected outcomes and prognosis, and symptom management. Periodic reviews include evaluation and, when necessary, changes to plans to ensure continued support for patients.

Access to Care & Care Continuity

Keystone providers are available 24 hours a day, 7-day-a-week. While our providers only make visits Monday through Friday, 8:00am-5:00pm, they can be reached by phone after hours for urgent needs.

A variety of communication options are available for the patient, and any caregiver, to communicate with the practitioner regarding the patient's care. Telephone, secure messaging, secure Internet, and other non-face-to-face consultation methods (i.e., email or secure electronic patient portal) are a few ways Keystone ensures our providers hear from you.

Comprehensive Care Management

Keystone Connect staff provide a systematic assessment of the patient's medical, functional, and psychosocial needs. Our approach allows for timely delivery of recommended preventative care services, medication management to avoid potential interactions, and coordination with caregivers and providers.

Transitional Care Management

Sometimes patients have changes in their lives which leads to necessary changes in their care. Keystone coordinates the transitions between providers and facilities to make these adjustments in patient care seamless. Our Care Management team orchestrates with families, living centers, and medical professionals to determine the best solution for our house call patients.

Additional Reading: What Is Transitional Care Management?

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