The Chronic Care Management (CCM) service is extensive. Following the precise guidelines in the Affordable Care Act (ACA) and from the Centers for Medicare and Medicaid Services (CMS), our CCM progam includes: 1) structured data recording of patient health information, 2) an electronic care plan addressing all health issues, 3) 24/7 access to care management records, 4) managing care transitions, 5) medication management 6) coordinating and sharing patient information with practitioners and providers outside the practice. Some of the CCM Scope of Service elements require the use of a certified EHR or other electronic technology.
Care Coach
Expand your care team and grow your practice, brand, and revenue while improving patient and satisfaction as well as reducing overall healthcare costs.
We not only focus on the high-risk patients, we also focus on the preventative and wellness needs of every patient.
Care Coaches identify unique care opportunities and services for patients beyond your usual daily schedule.
POPULATION HEALTH PLATFORM
Care Coach
Patient-Centered
Improving health and patient satisfaction begins with patient engagement and personalized and compassionate interactions.
VITAL
Patient-Centered Care Plan
In a systematic way to supplement regular doctor office visits, each patient will have access to his/her personal care plan:
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Create a personalized care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues).
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Provide the patient with a written or electronic copy of the care plan and document it's provision in the medical record.
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Ensure the care plan is available electronically at all times to anyone within the practice.
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Share the care plan electronically outside the practice as appropriate.
Care Plan
Each pesonalized care plan begins with a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment.
VITAL
Care Coordination
Care management includes services such as:
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Ensure timely receipt of all recommended preventive care services;
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Medication reconciliation with review of adherence and potential interactions;
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Oversight of patient self-management of medications.
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Manage care transitions between and among health care providers and care settings, including referrals to other clinicians;
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Follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.
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Coordinate care with home and community based clinical service providers.
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Facilitate communications among Patients, Eligible Practitioners, other clinicians treating a Patient.
Care Coordination
System-based care coordination and management.
VITAL
24/7 Access
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Ensure 24-hour-a-day, 7-day-a-week, 365-days-a-year access to care management services, providing the patient with a means to make timely contact with health care practitioners in the practice who have access to the patient’s electronic care plan to address his or her urgent chronic care needs.
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Ensure continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
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Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care via telephone, secure messaging, or secure Internet, in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
24/7/365
Access
Ensure 24-hour-a-day, 7-day-a-week care access.
Structured
Data
Recording
Little Data builds a BIG DATA solution
VITAL
Patient Profile
Record the patient’s demographics and create structured clinical summary record using certified EHR technology to include:
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family health history,
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patient health history,
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medications,
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medication allergies,
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problems.
CCM
Benefits
Improve care, improve the care experience, reduce overall cost of care.
Benefits
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Identify patients for chronic care management;
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Introduce and enroll eligible CCM patients;
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Provide each patient access to an easy-to-use online patient web portal and mobile application;
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Enable and support your patient, and your practice, with our services and software;
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Manage and coordinate care among all of the patient's providers;
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Provide certified electronic health records (EHR) transfer data through your EHR to populate patient profiles with records from your practice;
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Prepare a comprehensive care plan for every patient, including updates as necessary;
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Work directly with your practice staff to appropriately bill Medicare for CCM reimbursement;
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Provide an immediate solution without capital risk;
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Help coordinate your practice’s calendar to fill open appointments with eligible patients.
Education
Each Care Coach is continually trained in clinically researched data of the 40 most common chronic conditions, with advanced communication skills training to ensure better interaction with patients and providers.
Education
Each care plan is based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, sources (a comprehensive plan of care for all health issues).
Patient Engagement Measures
Using a series of assessments, measures, activities, and surveys, our Care Coaches will determine each patients level of understanding and determine appropriate engagement methods. The 4 levels include:
LEVEL
1
Disengaged.
Individuals are passive and lack confidence. Health knowledge is low. Goal orientation is weak. Adherence is poor. Their perspective: “My doctor is in charge of my health.”
LEVEL
2
Aware.
Individuals have some knowledge, but large gaps remain. They believe health is largely out of their control, but can set simple goals. Their perspective: “I could be doing more.”
Taking Action.
Individuals have the key facts and are building self-management skills. They strive for best practice behaviors, and are goal-oriented. Their perspective: “I’m part of my health care team.
LEVEL
3
LEVEL
4
Advocate.
Maintaining behaviors and pushing further. Individuals have adopted new behaviors, but may struggle in times of stress or change. Maintaining a healthy lifestyle is a key focus. Their perspective: “I’m my own advocate.”