Our Physician Services
Chronic illness can cause severe pain and discomfort resulting in many patients avoiding visits to
their primary care provider. However, seeing one’s primary care provider is extremely
important—even more so for those diagnosed with a chronic illness.
Agave physician services is bringing back the practice of visiting patients in their homes or
community living environment. Agave Physician Services brings qualified, professional primary
care providers directly into the homes of patients facing chronic illness relieving them of the
discomfort that may come with traveling to your health care providers office.
Also our providers spend more time with their patients ensuring you won’t have to fit all your
concerns and questions into a 15-minute visit.
Agave Physician Services provides exceptional healthcare in whatever setting you call home.
Our providers focus not only on treating diseases and injuries but also preventing them. We are
not a concierge service and believe quality healthcare should be afforded to everyone. We
proudly accept Medicare, Medicaid, and private insurance. Agave Healthcare is committed to
giving your immediate needs our immediate attention.
Transitional Care
Transitional care is the movement of a patient from one setting of care to another. Settings of
care may include hospitals, ambulatory primary care practices, ambulatory specialty care
practices, long-term care facilities, home health, and rehabilitation facilities. When a patient
transitions from one setting to another they are at an increased risk of adverse events due to the
potential for miscommunication as responsibility is handed to new health care provider.
Being discharged from a hospital or other care setting is a complex process and represents a
significant vulnerability for some patients. Safe and effective transfer of responsibility for a
patient’s medical care relies on effective provider communication and patient comprehension of
discharge instructions.
The goal of TCM is to improve communication and support the patient and their family after
discharge. It is designed to last 30 days and focuses on improved outcomes and avoiding
hospital readmission. To ensure there are no gaps in patient care, Agave Healthcare provides a
medical professional engaging in a face-to-face visit with the patient as well as additional visits
and or phone calls to ensure needs are being met.
Agave Physician Services will work with a patient’s primary care provider to transition a patient
back home along with the needed resources to be successful and remain at home.
Advanced Care Planning
For people living with one or more chronic condition, advance care planning is an important part
of chronic disease self-management. While some people living with a chronic disease enjoy
quality of life, the time may come when they are unable to speak for themselves or make their
own decisions regarding health care. Advance care planning involves learning about the types of
decisions that might need to be made, considering those decisions ahead of time, and then letting
others know—both your family and your health care providers—about your preferences.
Advanced care planning allows you to express your values, goals, and desires related to end-of-
life care. Advanced care planning is a fluid process and allows you to adjust your goals as the
situation changes. Navigating this process can be difficult and even stressful, as the terminology
and choices can seem overwhelming. Agave Healthcare can assist you and your family make
informed decisions and support any changes that occur over the course of a disease process.
Chronic Care Management
Chronic care management (CCM) offers additional help managing chronic conditions. CCM
includes a comprehensive care plan that lists your health problems and goals, other providers,
medications, services you have and need, and other information about your health. It also
explains the care you need and how your care will be coordinated. CCM is a critical component
of health care that contributes to better health for individuals living with chronic conditions.
CCM services are generally non-face-to-face services provided to Medicare beneficiaries who
have multiple (two or more) chronic conditions expected to last at least 12 months. Although
patient cost sharing applies to the CCM service, most patients have supplemental insurance to
help cover CCM cost sharing. Also, CCM may help avoid the need for more costly services in
the future by proactively managing patient health, rather than only treating severe or acute
disease and illness. Only one practitioner can provide CCM services during a calendar month
and the patient has the right to stop CCM services at any time (effective at the end of the
calendar month).
If you agree to this service, Agave Healthcare will prepare an individualized care plan, help with
medication management, provide 24/7 access for urgent care needs, give you support when you
go from one health care setting to another, review your medicines and how you take them, and
help you with other chronic healthcare needs.
Ready to continue?
If you feel Hospice and / or Palliative care is the right solution for you and your family, then we are here to help you take your first steps! Click below to either learn more about what Agave can specifically do for you, or contact us today so we can start giving you the time you need with the ones you love.
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Learn about what the Agave family and our team of caring experts can do for you and your loved ones during your time with Hospice.
Who is Agave?
Learn about what the Agave family and our team of caring experts can do for you and your loved ones during your time with Hospice.