Software

Intelligent Technology

For the first time, DATA IS AGGREGATED FROM ACROSS THE CONTINUUM OF PROVIDERS AND SOURCES, IN REAL TIME. Providers gain actionable insights within clinical workflows to increase productivity and improve patient outcomes.

"You Can't Do This With an EHR/EMR"

Our Chronic Care Management Platform:

Securely integrates with virtually any Medicare-certified EHR, from large-scale health systems to independent practice models;
Continuously stratifies patient data and sorts patients into high-, medium-, low- and rising-risk categories to assess: risks, hospitalization likelihood, non-adherence, motivation, and likelihood to experience higher risk;
Provides daily summary indicators and caseload, including tasks due for that day as well as a preview of upcoming work and any overdue items;
Recommends mitigations, facilitates medication review, and helps our clinicians plan their day and prioritize tasks;
Employs evidence-based assessments that auto-generate patient care plans;
Shares patient information and care plans at the point of care – across multiple EMRs – delivering necessary data to all providers;
Ensures patient privacy by safeguarding access to patient health information;
Provides a 360-degree view of each patient, including lab results, medication history, and documents;
Uses certified EHR to transfer patient data - including billing data - to your EHR and populate patient profiles with records from your practice.

*NO interruption of workflow, NO extra staff needed, and our service covers everything from integration to billing.

Technology Highlights:

OIG compliant 24/7 data capturing and billing;
Secure and compliant EHR platform
Data analytics and resource use;
Patient portal with electronic medical record;
Care coordination among all providers;
Health information exchange among all stakeholders;
Auto-generate patient care plans;
Patient engagement and education;
Medication therapy;
Transitional care;
Recommends mitigations and preventative plan services;
"Top of license" reimbursement;
And more...

Interoperable Data

Semantic interoperability—or the ability of two systems to exchange data in a meaningful way—remains a barrier to accurate data analytics and reporting. Effective data normalization and terminology management is critical to accurately capturing data – which must become a priority to maximize reimbursement within MACRA’s Quality Payment Program (QPP) under the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

To coordinate care, health systems need to aggregate potentially "disparate data" from multiple sources and share that patient data to providers as needed. Our technology enables care teams to provide coordinated care while working at "top of license".

Discover the only technology platform that delivers health IT and interoperability in a way previously considered impossible.

Continually identify, assess, and stratify patient data to improve outcomes and decrease overall costs.

As there are not enough providers to manage every patient continuously, this focus requires automation to support those providers and to carry out the large number of routine tasks that do not have to be performed manually.

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Staffing

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 program includes:

Structured data recording of patient health information
An electronic care plan addressing all health issues
24/7 access to care management services
Managing care transitions
Medication management
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.

Care Coach Access

24/7/365 access to care management services (providing the beneficiary 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 regardless of the time of day or day of the week). Care Coaches provide personalized interactions and facilitate communications among Patients, Eligible Practitioners, other clinicians treating a Patient. Communications methods shall include telephone, secure messaging, internet, or other asynchronous non-face-to-face consultation methods through specialized healthcare technology and software application (or “apps”) and the Patient Portal. Our bilingual team reduces barriers that limit communication. All data is integrated into your EHR allowing a 360 degree view of each patient, anytime, and from anywhere.

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:

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).
Provide the patient with a written or electronic copy of the care plan and document it's provision in the medical record.
Ensure the care plan is available electronically at all times to anyone within the practice.
Share the care plan electronically outside the practice as appropriate.

Care Plan

Each personalized care plan begins with a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment.

Care Coordination

Care management includes services such as:

Ensure timely receipt of all recommended preventive care services;
Medication reconciliation with review of adherence and potential interactions;
Oversight of patient self-management of medications.
Manage care transitions between and among health care providers and care settings, including referrals to other clinicians;
Follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities.
Coordinate care with home and community-based clinical service providers.
Facilitate communications among Patients, Eligible Practitioners, and other clinicians treating a Patient.

Care Coordination

System-Based Care Coordination and Management

24/7 Access

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.
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.
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

Patient Profile

Record the patient’s demographics and create structured clinical summary record using certified EHR technology to include:

Family health history
Patient health history
Medications
Medication allergies
Problems

Improve the Care Experience and Reduce the Overall Cost of Care Benefits

Identify patients for chronic care management;
Introduce and enroll eligible CCM patients;
Ensure fast 24/7 access to non-emergency care;
Provide each patient access to an easy-to-use online patient web portal and mobile application;
Enable and support your patient, and your practice, with our services and software;
Manage and coordinate care among all of the patient's providers;
Provide certified electronic health records (EHR) transfer data through your EHR to populate patient profiles with records from your practice;
Prepare a comprehensive care plan for every patient, including updates as necessary;
Work directly with your practice staff to appropriately bill Medicare for CCM reimbursement;
Provide an immediate solution without capital risk;
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 most common chronic diseases, with advanced communication skills training to ensure better interaction with patients and providers.