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.
The hub of our service
We provide an in-clinic Care Manager to schedule and conduct all AWVs. Our Care Manager also enrolls eligible patients into the 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 CCM program and drive quality scores for your clinic and/or hospital.
Building patient relationships
Our prevailing goal for our CCM program is to build a personal, one-on-one relationship with each of our patients. To accomplish this goal, every CCM patient is assigned a dedicated Care Manager that builds trust and patient confidence. We develop customized care plans for each CCM patient based on your direction that improves overall health and continuity of care between office visits.
Successful hospital transition
We provide in-hospital Care Managers 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 readmissions, reduces costly ER visits, and drives overall quality scores.
Quality that matters
We customize patient interactions across our integrated spectrum of services (AWVs, CCM, and TCM) to align with key quality scores for your clinic and/or hospital. We provide a focused, disciplined approach to ensure that we are driving the appropriate patient behavior to improve fulfillment of quality “activities”.
The number one issue
The most pressing issue for most seniors is the management of the many medications that they take. Our comprehensive med management program helps to lower costs, provides continual review and reconciliation of their meds, and offers innovative monitoring and pharmacogenetic tests to optimize compliance and efficacy.