Care Coordination

Our programs allow you to move your organization to a model of improving wellness and delivering value based care, while improving patient experience and earning new recurring revenue.

About Us

We offer a turnkey program that allows you to provide comprehensive chronic disease management and care coordination services for your patients.  Our dedicated, compassionate, and experienced clinicians, combined with the right technology provides the most effective and comprehensive care coordination services available.

Our Services

In America, 191 million people have one chronic disease, while 75 million have two or more chronic diseases. Our programs are proven to positively impact health outcomes and reduce costs through effective chronic disease and transitional care management.

Our Care Coordination services include:
(Click on the + below for full description)

Chronic Care Management (CCM)

CCM focuses on managing those patients with two or more chronic conditions.  Medicare and certain other payers compensate you for providing this service outside of the office setting.  Offering CCM enables you to sustain and grow your practice while improving quality and patient satisfaction.  We work for you, developing and managing the care plans for those enrolled in the program.  Our turnkey program brings to you the technology and experienced clinical staff that will allow you to effectively implement this program for your practice.

Remote Patient Monitoring (RPM)

RPM reimbursement now brings additional tools for your practice to monitor your patients on a continuous basis.  RPM allows a patient to use a connected medical device and send the data to the health professional.  Our solution coordinates all logistics and monitoring services for your RPM program.  We coordinate getting the devices to your patients, monitoring the data, and reporting to you the results for easy management of your program.

Behavioral Health Integration (BHI)

BHI is program that provides patients with psychiatric or behavioral health conditions services to effectively manage their condition.  This effective strategy has proven to improve outcomes for those patients with mental or behavioral health conditions.  Our Behavioral Health Managers work with you and your patients to deliver a high-quality program.  We provide the behavioral health care assessment, planning, and necessary interventions that have proven to deliver improved results with this patient population.

Transitional Care Management (TCM)

TCM is a program that is designed to improve the 30-day transition of care for those patients that are discharged from hospitals or other facilities as outlined by CMS.  This has proven to significantly improve patient satisfaction and care coordination, while lowering the readmission rate for those that are offered this service.  We understand how difficult it can be to coordinate these services for your patients.  We work directly with your team and the facilities that your patients are being discharged from to develop a streamlined process.  We coordinate all discharge and medication information, education, and engagement with the patient and their necessary post-discharge follow up appointments.  This allows your patients to receive highly coordinated care during this critical time.

Annual Wellness Visits (AWV)

The Annual Wellness Visit (AWV) is a yearly appointment to create or update a personalized prevention plan.  Medicare covers an AWV providing Personalized Prevention Plan Services (PPPS) for beneficiaries who:

  • Are no longer within 12 months after the beneficiary’s eligibility date for Medicare Part B benefits
  • Have not received an IPPE or AWV within the past 12 months

We identify which wellness program your patients are eligible for up front.  Our AWV and IPPE program simplifies this entire process for your practice.  The care coordinators will work with patients and do the telephonic portion of the Wellness Visit, and will coordinate with the patient and your office the necessary in-office portion of this visit.  Your office will have all necessary assessments through our telephonic engagement prior to their scheduled office visit.

Advanced Care Planning

Advance care planning (ACP) is the time a physician or other qualified health care professional spends with a patient, family member, or surrogate to explain and discuss advance directives.  CMS pays for voluntary Advance Care Planning (ACP) under the Medicare Physician Fee Schedule (PFS).  If provided in conjunction with the AWV, Medicare waives the coinsurance and deductible.  Our program simplifies this entire process for your practice.  Our team telephonic portion and any other coordination of the ACP.  Then we will coordinate with the patient and your office the necessary in-office portion of this visit.  Your office will have all necessary assessments through our telephonic engagement prior to their scheduled office visit.

Chronic Disease Management/Behavioral Health Integration

  • Personal Care Coordinator for each patient
  • Develop a personalized care plan that addresses the chronic conditions
  • Administration of behavioral validated clinical rating scale (BHI)
  • Facilitation and coordination of behavioral health treatment plan (BHI)
  • Advocacy to assist with appointments, billing, and insurance issues
  • Technology provides awareness and updates with patient and provider

Remote Patient Monitoring

  • Coordination with RPM vendor to provide the device and setup
  • Custom IT Technology to continuously track and document monitored data
  • Quickly identify results outside of clinical guidelines. Engage patient and provider as directed for immediate intervention
  • Compile all trended data and documentation for clinical decision making and billing

Annual Wellness Visit & Advanced Care Planning

  • Coordinate prior to the office visit the required assessment and documentation to qualify for the Welcome to Medicare Visit
  • Coordinate prior to the office visit the required assessment and documentation to qualify for the Initial and Annual Wellness Medicare Visit
  • Review with patient and document all elements of Advanced Care Planning

Transition Care Management

  • Coordinate transition of care for 30 days post discharge
  • Engage patient within 2 days of facility discharge
  • Schedule appointments and perform medication reconciliation
  • Face-to-face physician or NPP visit within 7-14 days
  • Post discharge patient satisfaction survey (HCAHPS Transition of Care)

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