Putting together the Medicare preventative healthcare puzzle
Over the last several years, Medicare has launched several preventative healthcare initiatives to reduce the overall growth in the spiraling cost of healthcare while delivering better patient care. By and large, these programs have been difficult for Providers to implement on their own and, as standalone programs, have not delivered the desired benefits. We have successfully unlocked the potential of these programs by integrating them into one cohesive whole, delivering outstanding results and uncovering hidden synergy between them.
Our secret sauce
Better patient outcomes start with building and nurturing a personal, one-on-one, trusted relationship with each patient. We do this by assigning a dedicated Personal Health Advocate (PHA) to each patient. By interacting with the same PHA every month, we are able build a close bond with each patient. We leverage these relationships to gather deeper health-related insights that helps to improve the diagnosis and treatment of all patients. We are also able to follow the patient over time to track results and improve their level of compliance.
The key to better patient outcomes
We believe that RPM is the key to driving better healthcare outcomes. By providing monitoring device(s) specifically targeted at the patient’s chronic illnesses, the patient is able to take daily readings in the convenience of their own home of their most critical vital signs. We actively monitor these readings and are able to alert their Provider if they should fall outside the agreed upon guidelines. In this manner, action can be taken before the situation worsens and requires avoidable ER visits or hospitalization.
Care Coordination
Our overarching goal for both our RPM and CCM programs is to build a personal, one-on-one relationship with each of our patients and individualize the specific support they receive. We go well beyond the standard guidelines to include things from fall prevention and emergency preparedness to identifying and addressing SDoH and Daily Living needs. As an integral part of our program, we develop customized care plans for each patient under the direction and guidance of their Provider that improves their overall health and continuity of care between office visits.
In-depth annual review
We provide an in-clinic Personal Health Advocate to schedule and conduct all AWVs. Our PHA also enrolls eligible patients into the RPM or CCM program. During the AWV visit, we offer Advanced Care Planning (ACP) to all patients. An essential component of our program is our “gaps in care” service that will uncover missing Medicare preventative health services. We also leverage the input from the AWV encounter to feed our monthly RPM and CCM programs and drive quality scores for your clinic and/or hospital.
Successful hospital transition
We provide in-hospital Personal Health Advocates to manage the entire TCM process. We work closely with both case management and discharge to ensure complete patient coverage. When possible, we discuss the TCM program with the patient while in the hospital. Our TCM program lowers re-admissions, reduces costly ER visits, and drives overall quality scores.
Results that matter
We embed your quality metrics into our proprietary software application. This allows us to customize our patient interactions across our integrated spectrum of services to align with key metrics for your clinic, hospital, or ACO. We provide a focused, disciplined approach to ensure that we are driving the appropriate patient behavior and compliance to improve fulfillment of quality “activities”. Because this is built into our workflow, nothing is overlooked or missed.