Supportive Care – Affinia Health Network

Supportive Care Program

The Supportive Care Program provides comprehensive team based care for vulnerable and frail patients throughout the communities we serve. The team targets our sickest, often homebound population and provides consultative In-Home Needs Assessments to augment care, make recommendations, address social influencers of health, and drive appropriate referrals.

The Supportive Care Team

Image depicting how the Supportive Care Program functions

FAQ

Q: Who are the Supportive Care Program providers?

A: Kimberly Harper DNP AGPCNP-C, Jonathan Davis CM BSN, and Sandra Stein LPN.

Q: Who becomes the primary care provider after a patient enters the program?

A: The patient will remain with their current PCP. Supportive Care is a consultative service. Any orders placed by the team will require the PCP’s signature.

Q: Where does documentation occur?

A: All documentation is completed in Athena.

Q: Is there communication back to the PCP?

A: Yes. A warm handoff is provided to the patient’s PCP and care manager.

Typically 14 to 30 days after the assessment, a patient case summary is provided including, but not limited to:

Mental, physical, safety, social, and family history reviews/screenings
Medication reconciliation with pharmacy recommendations
Social determinants of health outputs and community referrals

Referral Criteria

Patient has a qualifying insurance product (value based program)
Patient has established care with an Affinia PCP
Patient has chronic conditions eligible for care management services
Patient is 18 years or older
Patient has two or more of the following risk factors:
- Functional deficits
- Four or more comorbid health conditions
- Six or more medications
- Two or more hospitalizations with the last 6 months
- Inadequate support system
- History of non-adherence to therapeutic regimen

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