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:

  1. Chronic Care Management
  2. Behavioral Health Integration
  3. Remote Patient Monitoring
  4. Transition Care Management
  5. Annual Wellness Visit
  6. Advanced Care Planning

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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Learn More

Our experts at Visium HealthLink can help you navigate this complicated environment of billing and insurance benefits. We will work and negotiate on your behalf with the providers and insurance companies to assure your bills are fair and accurate.