Centered Care
Services
Centered Care can incorporate care management service lines currently employed by our group in your practice to include.
Chronic Care Management
(CCM): The Centers for Medicare & Medicaid Services (CMS) defines CCM as care coordination services performed outside of the regular office visit for patients with multiple (TWO or MORE) chronic conditions that are expected to last at least 12 months or until the patient’s death, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. CMS allows providers to be reimbursed for CCM services offered to patients.
Chronic Care Management
(CCM): The Centers for Medicare & Medicaid Services (CMS) defines CCM as care coordination services performed outside of the regular office visit for patients with multiple (TWO or MORE) chronic conditions that are expected to last at least 12 months or until the patient’s death, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. CMS allows providers to be reimbursed for CCM services offered to patients.
Kiara noticed a remarkable trend with patients and their health, and it revealed that they weren’t knowledgeable of their diseases and how to properly manage their own healthcare . Patients often didn’t know the names of any medications they were prescribed, why they were taking it, or non compliant for many different reasons. Medication mismanagement often led to decline and unnecessary hospitalizations.
Patients were left untreated for lack of knowledge for proper resources. Patients just didn’t understand why and how they even got sick in the first place and how to improve their quality of life. Operating at the bedside as a nurse, Kiara learned that her presence during those 12 hours were many patient’s saving grace as she was their educator, advocate, and interventionist.
Inpatient Acute Care Hospital
Inpatient Psychiatric Hospital
Long-term Care Hospital
Nursing Home
Inpatient Rehabilitation Center
Hospital Outpatient Observation/partial Hospitalization
Behavioral Health Management
(BHI): A BHI program combines mental health care with primary care. Behavioral health is an umbrella word that includes mental health, substance addiction disorders, and physical symptoms associated with stress. BHI is a monthly remote service that is reimbursable if several key requirements are met.The patient must present with at least one behavioral health condition to be eligible for this program. Medicare Part B will cover up to 80% of the program’s cost. Other insurances, such as Medicaid or private companies, may also cover this cost. These can include, but are not limited to:
A Systematic Assessment
Facilitation And Coordination Of Behavioral Health Treatment
Continuous Patient Monitoring
A Continuous Relationship With A Designated Care Team Member
Care Plan Creation And Revision
Remote Physiologic Monitoring
(RPM): Is a telehealth program offered by Medicare. Your clinic can collect patient vitals on a continuing basis, in between regular office encounters, using a variety of digital devices. This information can then be used to guide care decisions. Any Medicare Part B patient can sign up for remote monitoring services. It covers 80% of this amount, with numerous supplemental insurance policies covering the remainder. In addition, the program is covered by non-Medicare primary insurance providers. Patients can take devices home with them that are programmed to collect readings daily and digitally transmitted to their provider. These readings can include, but are not limited to:
Blood Pressure
Blood Glucose
Weight
Heart Rate
Remote Physiologic Monitoring
(RPM): Is a telehealth program offered by Medicare. Your clinic can collect patient vitals on a continuing basis, in between regular office encounters, using a variety of digital devices. This information can then be used to guide care decisions. Any Medicare Part B patient can sign up for remote monitoring services. It covers 80% of this amount, with numerous supplemental insurance policies covering the remainder. In addition, the program is covered by non-Medicare primary insurance providers. Patients can take devices home with them that are programmed to collect readings daily and digitally transmitted to their provider. These readings can include, but are not limited to:
Blood Pressure
Blood Glucose
Weight
Heart Rate
Principal Care Management
(PCM): Much like CCM, PCM is intended to serve people with ONE chronic condition. For a patient to be eligible for PCM, the patient must have a diagnosis that is projected to persist three months to a year, or until death, may have resulted in a recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation/decompensation, or functional deterioration. One of the key goals of PCM is to address a patient’s chronic disease as soon as possible, stabilizing it so that the patient’s overall care can return back to the patient’s primary care physician.
Annual Wellness Visit
Is not like an annual physical exam that is performed by a provider, but rather a patient centered individualized preventative plan of care. This program can benefit both patient and provider as follows but not limited to:
A Systematic Assessment
Translating The Data In The Medical Record Into Information That Impacts The Health And Wellness Of The Patient
Perform And Evaluate The Depression, Cognitive, And Falls Risk Assessments
Educate Patients On Home Safety
Connect Patients With Community Resources To Improve Lifestyle Behaviors
Advanced Care Planning
The Centers for Medicare and Medicaid Services (CMS) offers this program as a reimbursable procedure. A skilled Advanced Care Planning Professional assists the patient to put in words their choices that relate to their end of life care. Our professionals can meet with your patient in office personally to assist with this need.