Transforming Health

IMBUEfoundation’s approach to address local health disparities and improve care delivery is very unique. We rely solely on Nurse Practitioners (NPs) to act as the “clinical concierge” and accept the role of front-line, minute-to-minute information providers; which provides counseling, monitoring, and stewardship activities. The activities of the “clinical concierge” include: coordinating care delivery and aligning healthcare objectives, clarifying different care plans, reviewing and presenting treatment options to patients and families, providing education regarding therapeutic alternatives, monitoring and updating records, and organizing family/team meetings as needed.

Modes of service:

Rural Health Collaborative

  • Identify needs for the region, including pockets of special needs within the counties
  • Develop strategic directions for improvement of health in the region
  • Work with health systems and independent providers to integrate clinical health needs with social, behavioral, and environmental needs that impact health and clinical outcomes
  • Integrate the work of the foundation and other local organizations into broader regional initiatives

Care Coordination

  • Deliver the direct care and coordinate the multifaceted plan of care for patients
  • Serve as a consultant in improving care based on expertise in area of specialization
  • Identify learning needs of various populations and contribute to the development of educational programs and resources
  • Evaluate the impact of changes in clinical practice and formulate recommendations regarding appropriateness and cost-effectiveness
  • Build collaborative relationships with physician care teams, healthcare organizations/health systems

Transportation Service

  • Partnership with ride-share (Lyft) to provide car service to provider appointments, obtain groceries, and other activities that support a culture of health