Navicare by quadra Health

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Bridging the gap from hospital to home — safely, smoothly, and collaboratively.

Transitions of care are one of the most vulnerable moments in a patient’s healthcare journey. Medication errors, missed follow-up appointments, communication breakdowns, and confusion about care plans can quickly lead to complications — and unnecessary hospital readmissions.

NaviCare’s Transitional Care Management (TCM) program provides structured, proactive medical support during the critical 30 days following hospital discharge.

 What We Do 

Our team of Family Nurse Practitioners, Psychiatric Mental Health Nurse Practitioners, and Registered Nurse Care Coordinators work closely with patients, families, hospitals, and primary care providers to ensure:

• Timely post-discharge contact (within 48 business hours)  
• Comprehensive medication reconciliation  
• Review and clarification of discharge instructions  
• Coordination of specialty and primary care follow-up  
• Behavioral health stabilization and medication management (when needed)  
• Chronic disease management and symptom monitoring  
• Identification and removal of barriers to recovery  
• Clear communication between all members of the healthcare team  

We support patients discharged from Las Vegas and Henderson hospitals who:

• Have multiple chronic conditions  
• Experienced recent hospitalization or ED visits  
• Require medication changes or complex care coordination  
• Have co-occurring medical and behavioral health needs  
• Are at risk for hospital readmission  

Research consistently shows that structured transitional care:

• Reduces 30-day hospital readmissions  
• Improves medication adherence  
• Enhances patient satisfaction  
• Strengthens provider communication  
• Improves overall health outcomes  

Our model is built on four pillars:

Patient Support. 

Provider Communication. 

Medication & Care Plan Coordination. Readmission Prevention.

• Telehealth-focused for rapid access and convenience  
• In-clinic or in-home visits when clinically appropriate  
• Medicare, Medicare Advantage, and commercial payer participation  
• Seamless coordination with primary care and specialty providers  

At NaviCare, we don’t replace your primary provider — we strengthen the transition. Our goal is to stabilize, coordinate, and safely guide patients through recovery so they can return confidently to their ongoing care team.  

Proactive care between visits — because health doesn’t only happen in the clinic.

Many serious complications don’t develop overnight — they build gradually. Subtle changes in blood pressure, blood glucose, oxygen levels, or weight can signal worsening chronic disease long before a patient feels critically ill.

NaviCare's Remote Patient Monitoring (RPM) program provides continuous clinical oversight from the comfort of home, allowing our care team to detect changes early, intervene quickly, and prevent avoidable hospitalizations.

Remote Patient Monitoring uses secure, FDA-approved home devices to track vital health data such as:

• Blood pressure
   
• Blood glucose
   
• Weight
   
• Pulse oximetry
   
• Heart rate
   
• Other condition-specific measurements
   

These readings are transmitted electronically to our clinical team for review and ongoing management.

1. Enrollment & Device Setup
   We provide easy-to-use monitoring equipment and training.
    
2. Daily Monitoring
   Patients take readings at home according to their care plan.
    
3. Clinical Review
   Our nurses and nurse practitioners review data regularly and identify concerning trends.
    
4. Timely Intervention
   If abnormal patterns are detected, we contact the patient, adjust care plans, coordinate with the primary provider, or escalate care when necessary.
    

Remote monitoring is ideal for patients with:

• Hypertension
   
• Diabetes
   
• Heart failure
   
• COPD or asthma
   
• Chronic kidney disease
   
• Complex multi-morbidity
   
• Recent hospital discharge with elevated risk of readmission
   

Early intervention saves lives and reduces costs.

Structured RPM programs have been shown to:

• Reduce hospital readmissions
   
• Improve blood pressure and glucose control
   
• Enhance medication adherence
   
• Increase patient engagement
   
• Provide peace of mind for families
   

By identifying changes early, we can intervene before small problems become medical emergencies.

Our RPM program is not isolated monitoring — it is integrated medical management.

• Care is overseen by Family Nurse Practitioners and Psychiatric Mental Health Nurse Practitioners.
   
• Registered Nurse Care Coordinators provide active oversight.
   
• Communication is shared with the patient’s primary and specialty providers.
   
• Behavioral health considerations are incorporated when appropriate.
   

RPM is especially powerful when combined with Transitional Care Management (TCM) and Chronic Care Management (CCM) to create a seamless continuum of support.

Remote Patient Monitoring is typically covered by Medicare, Medicare Advantage, and many commercial plans when medical necessity criteria are met.

At NaviCare, we believe healthcare should be proactive — not reactive.
Remote Patient Monitoring allows us to extend expert clinical care beyond the walls of the clinic and into everyday life.

Ongoing support for complex health conditions — beyond the office visit.

Living with multiple chronic conditions can feel overwhelming. Managing medications, coordinating appointments, monitoring symptoms, and navigating the healthcare system often becomes a full-time job — especially for patients with complex medical needs.

NaviCare's Chronic Care Management (CCM) program provides structured, ongoing clinical support for patients with two or more chronic conditions expected to last at least 12 months or until the end of life.

Our goal is simple:
Improve stability. 

Prevent complications. 

Strengthen long-term outcomes.

Chronic Care Management is a Medicare-supported service that provides non-face-to-face care coordination between office visits. It ensures patients receive continuous clinical oversight — not just episodic care.

Our care team works proactively each month to:

• Develop and maintain a comprehensive, personalized care plan
   
• Coordinate care among multiple providers and specialists
   
• Reconcile medications and monitor adherence
   
• Address barriers to treatment and social determinants of health
   
• Monitor disease progression and symptom changes
   
• Provide direct access to clinical support when concerns arise
   

CCM is designed for patients with two or more chronic conditions, such as:

• Hypertension
   
• Diabetes
   
• Heart disease
   
• Chronic kidney disease
   
• COPD or asthma
   
• Depression or anxiety
   
• Autoimmune conditions
   
• Chronic pain disorders
   

These conditions often interact — and without coordinated oversight, can lead to avoidable emergency visits and hospitalizations.

1. Comprehensive Care Plan Creation
   We develop a detailed, individualized care plan addressing medical, behavioral, and social needs.
    
2. Monthly Clinical Oversight
   Our registered nurse care coordinators and nurse practitioners provide structured monthly support and documentation.
    
3. Medication & Treatment Review
   We monitor medication changes, side effects, and adherence.
    
4. Care Coordination
   We communicate with primary care providers, specialists, home health agencies, and family caregivers.
    
5. 24/7 Access to Care Plan Support
   Patients have access to assistance when they need guidance.
    

Chronic conditions account for the majority of healthcare utilization and cost. Without coordinated oversight, patients are at increased risk for:

• Disease progression
   
• Medication errors
   
• Emergency department visits
   
• Hospital readmissions
   
• Fragmented care
   

Structured CCM programs have been shown to:

• Improve disease control
   
• Increase patient engagement
   
• Reduce hospital utilization
   
• Enhance medication adherence
   
• Improve quality metrics
   

Chronic Care Management becomes even more powerful when integrated with:

• Transitional Care Management (TCM) after hospital discharge
   
• Remote Patient Monitoring (RPM) for real-time physiologic oversight
   

Together, these services create a seamless, continuous model of care — especially for high-risk patients.

Chronic Care Management is typically covered by Medicare, Medicare Advantage, and many commercial plans when eligibility criteria are met. Patients must provide consent to participate.

At NaviCare, we believe chronic disease management should be proactive, coordinated, and compassionate.

CCM allows us to extend structured medical oversight into everyday life — helping patients stay stable, supported, and safely at home.