Providers
We offer a variety of support systems to our local medical providers. We work in collaboration to ensure that our medical providers are successful in the community by supporting them to meet CMS Star Ratings and Clinical Quality Measures.
Chronic Care Management
CCM represents non-face to face care coordination for patients with multiple chronic conditions. CCM services include five core activities: recording structured data in a patient’s health record; maintaining a comprehensive care plan for each patient; providing 24/7 access to care; comprehensive care management; and transitional care management; Through CCM and complex CCM, the Center for Medicare & Medicaid Services (CMS) pays for
non-face-to-face care coordination services furnished to Medicare beneficiaries who reside in the community setting that meet the following requirements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline; and Comprehensive care plan established, implemented, revised, or monitored. With CCM, our clinical pharmacists can fill in the gaps in care when patients are not able to see their health care providers in person for an office visit. CCM provides extra revenue for primary care practitioners.
Remote Care
Remote patient monitoring (RPM) is a service that involves patient monitoring and followup by clinical staff remotely. Clinical pharmacists can followup with patients virtually while monitoring patients’ health parameters for excursions or outliers. This allows for thorough patient care and management and leads to better outcomes as providers cannot follow up with patients in between their annual medical visits.
Transitions of Care
Transitions of care (TOC/TCM) is defined as the movement of a patient from one health careprovider or setting to another and the corresponding provision of patient care services. The goal is for pharmacists to improve the quality of patient-centered care and reduce health care expenditures. Non–face-to-face services provided by our clinical pharmacists include: Reviewing discharge documents; Reviewing need and follow-up of lab, imaging, and test results; Establishing referrals; Scheduling follow-up appointments; Interacting with providers who will assume or reassume patient care; Arranging community resources needed; Educating patient, family, caregiver, or guardian; Assessing adherence and manage medications; Assisting with patient access to care and medications. The essence of TCM services is to reduce hospital readmission rates and reduce overall healthcare spending costs.
Implementing Chronic Care Management at Your Practice
With one in four American’s living with at least one chronic illness, it is not surprising that over 80% of primary care providers describe themselves as at full capacity or over extended.
Patients with complex health conditions and concerns utilize more resources, calling and coming into the office more frequently. The additional calls and visits put a strain on front desk staff and nurses, limiting other patients ability to access healthcare resources. This can result in a negative impact on your practice’s patient satisfaction and retention.
Practices are facing the challenges of keeping up with increased demand for healthcare and being penalized by Medicare with a potential 7% payment adjustment tied to the completion of specific quality and performance measures.
Partnering with Healthywayzz LLC can act as a seamless extension of your practice and can be a valuable resource for you and your patients.
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