Step 1
1. Referral
The journey begins when a provider practice identifies a patient who may benefit from BloomCare services. BloomCare contacts the patient and/or caregiver to explain BloomCare, review available services, answer questions, and support enrollment. This step is designed to build trust and make sure the patient and caregiver understand that BloomCare extends the provider's care team between visits.
Step 2
2. Assessment
Every patient goes through a thorough onboarding assessment. The RN reviews diagnoses, medications, recent hospitalizations, symptoms, goals, social barriers, caregiver involvement, communication preferences, safety concerns, and current care needs. This assessment helps BloomCare understand the whole patient, not just a diagnosis list.
Step 3
3. Care Plan
Each patient receives a detailed and individualized care plan unique to them. The care plan reflects the patient's conditions, goals, risks, medications, support needs, education needs, caregiver role, and escalation instructions. The care plan is updated over time as the patient's needs change.
Step 4
4. Ongoing Support
BloomCare RNs provide recurring touchpoints, education, adherence support, symptom review, medication support, appointment reminders, SDOH screening, caregiver communication, and care plan reinforcement.
Step 5
5. Escalation
When a patient reports worsening symptoms, abnormal readings, medication issues, post-discharge concerns, wound changes, behavioral health concerns, or other red flags, BloomCare RNs escalate appropriately. RNs can notify the provider practice and coordinate with designated on-demand providers on behalf of the practice for escalations requiring same-day or immediate attention.
Step 6
6. Outcomes Visibility
BloomCare tracks engagement, needs, risks, escalations, care plan progress, and patient barriers so practices have better visibility into what is happening between visits.
