Our mission is to improve our member’s health through building nurturing and trusting relationships in their home
Organization Overview
Medical group practice with 34 practitioners / 8 practices (DMC affiliates).
Serve elderly, disabled, and patients with severe persistent mental illness (SPMI) coupled with complex chronic medical conditions.
Practice across four counties (Wayne, Macomb, Oakland, and Washtenaw).
Care Model
Intensive home-based primary care and urgent care and enhanced care management service model.
Engage the highest-risk patients to holistically address clinical, social, and behavioral needs.
Key Partnerships
CM/CC Services
Specialty Care - Cardiology, etc
Local Area Agency on Aging
SNFs, LTC
Mental Health Authority
Laboratories
Mobile Urgent Care Team
Mobile Labs and Diagnostics
Leading Consulting Firms to support DCE operations*
Renovis has been selected by CMS to participate in the first cohort of Direct Contracting Entities (DCEs) as a High Needs Population DCE
CMS Direct Contracting Overview
1 of 51 awardees nationwide
1 of 6 awardees in Michigan; others include
-
Transitional housing – removal from environments unfavorable to success
-
Northern Michigan Health Network
-
Oakstreet Health Medical Partners
-
Primaria Independent ACO, LLC
-
Region VII Area Agency on Aging
Global risk payment model
Six-year demonstration starting April 2021
Potential to expand participation to Geographic model “Geo” in the future (2022 and 2025)
Renovis Health High Needs DCE
Home-based Primary and Acute Care for high need patients
High-touch Care Management Model/Pods
Address complications that drive utilization and costs (e.g., ER visits, IP admissions) through:
-
Mobile Urgent Care with same-day Lab/Diagnostics
-
In-home IV therapies, wound care, etc.
-
Transportation, Medication, and Food Access
-
Transition of care visits. Post-Acute Care management
-
Access to community programs
Renovis Care Model
300 Patients/Pod
1 Care Manager
1-2 Care Coordinator
Long-Term Support Services (LTSS) Behavioral Health/Substance Use Disorder supports Transportation coordination
Expertise embedded in the Care Management Pods
Long-Term Support Services Coordination
Waiver Experience
Area Agency on Aging Liaison
Complex DME
Food Equity and Support
Behavioral Health (BH) /Substance Use Disorder supports Service Access
BH Vendor Liaison
PIHP* Liaison for Duals
Opioid Therapeutic Management Referrals
Essential Pod Functions
Transitions of Care
&
Post-Acute Care Coordination
&
Medication and Therapeutic Management
Care Management Pod Structure
Transitions of Care Functions
The Care Manager pods will be responsible for tracking, and intervening where appropriate, on patients transitioning from one care environment to another. The pods will also provide oversight of Post-Acute Care needs.
Core competency of all pods.
ADT Feeds from MiHIN
Transition of Care Documents conveyed to Pods and Practices
Designed to support Aging in Place.
Working relationship with HHC agencies and Community supports.
Post-Acute Care Functions
The Care Manager pods will be responsible for tracking, and intervening where appropriate, on patients discharged from facilities such as hospitals, skilled-nursing and long-term care facilities.
Core Competency of all Pods.
Skill-in-Place
Skilled Nursing Facility (SNF) Waiver
Network Management - SNF Ranking.
Project BOOST/RED/AHRQ Methodology.
Presence at local Post-Acute Care Management Programs (e.g. DMC, SNFs).
Medication and Therapeutics Management Program
-
Med Reconciliation
-
Med Compliance
-
Readmit avoidance
-
Retail Pharmacy Integration
Nurse Call Center
Mobile Urgent Care Team
The Mobile Urgent Care Teams will be available to evaluate and stabilize patients within their homes. Hospital at Home function.
Team design:
Nurse Practitioner (NP), Medical Assistant (MA), treatment Nurse as needed
Service Offering:
On-site stabilization - antibiotics, infusions, labs and imaging.
Call Center Support
24/7 support for patients and families
Direct contact with NP, Care Manager, Care Coordinator
Mobile Imaging:
24/7, Plain films - CXR, Hip Films (falls) Vascular Imaging - venous doppler/Echo Stat results, Smart-Phone image retrieval, On-call Radiologist
Mobile Urgent Care Teams
West Woodward Team
East Woodward Team
7a-7p
Call-Center Dispatch
Nurse Practitioner to lead team
Medical Assistant support
Treatment Nurse as needed
Medical Director Support
All teams will be equipped with emergency kits
EMS activation as needed
Stabilize in the homep
Mobile Imaging/Lab support
Paramedic Pre-EMS Interventions
Paramedics increasingly used in the Home and ED
Urgent (non-911/Emergent) assessments in the home
Non-Red-Light Transports
Tele-Health interface with Physician/Nurse Practitioner
Post-Acute Presence
Renovis Call Center
The Call Center will serve as a direct link between aligned beneficiaries and Renovis Case Management staff and Care Coordinators
-
24/7 with scripted Work-Flow
-
CEHospital at Home Interface
-
Telehealth Support
-
AM Call Log sent to Care Manager Pods
Renovis Organizational Structure
Renovis Corporate Officers
Dr. Reginald Eburuche, CEO
University of Michigan, BS University of Maryland, Medical School Wayne State University, Residency Health industry – senior executive 16+ yrs
Mr. Olisaeloka I. Dallah, COO
University of Michigan, BA Michigan State University, Executive MBA Certified Fraud Examiner (CFE) Health / Non-Profit / Entertainment / Financial - senior executive 17+ yrs
Mr. Gerald Caine, CDO
Fisk University Health industry – executive 12+ yrs