Structured Ambulatory Care Coordination Support for Outpatient Practices
KSM SupportLink launch offers support to patients through referral-based outreach, whole person assessment, care plan development, resource linkage, follow-up, and provider reporting.
Ambulatory Care Coordination Core Service
The offered services enhance patient care by ensuring seamless communication and collaboration among healthcare providers and community health partners between visits.
Care Management involves coordinating care for patients, ensuring they receive appropriate follow-ups, interventions, and services.
Patient Education involves educating patients on the psychosocial resources available within their community, the benefits of those resources to reduce access-related barriers, and linkages to those resources and support - offered with warm handoffs.
Referral Coordination involves ensuring patients are referred to the right specialists (based on their insurance), and that necessary information is shared between primary care and specialty providers (within our scope). This minimizes delays and improves care continuity.
Telehealth Services involves utilizing technology to provide remote initial Whole-Person assessments and follow-ups, making it easier for patients to access care without needing to travel.
Our launch service is designed to work alongside the provider office with a practical, repeatable workflow. The service is designed to help practices support patients between visits while improving follow-through and helping address psychosocial and access-related barriers.
How We Support Practices
KSM SupportLink is designed to support the provider office, not replace it. We help extend follow-up and coordination support while keeping medical guidance and clinical decision-making with the provider team.
Whole-Person Support
Our model is built to identify barriers that affect whether patients can move forward with care. This includes psychosocial, social determinant, and access-related challenges that may affect follow-through between visits.
Pilot-First Approach
KSM SupportLink is currently designed to launch through a focused pilot structure so practices can evaluate fit, workflow alignment, and reporting value before moving into a longer-term engagement.
Referral-Based Outreach
Support begins with referrals received from the practice and continues based on care plan, severity, and identified need.
Resource Linkage
KSM SupportLink helps patients connect to transportation support, community resources, and other services relevant to identified barriers.
Provider-Aligned Reporting
Practices receive structured updates that help them understand outreach activity, patient progress, unresolved issues, and follow-up needs.