Care for Patients with Chronic Conditions
75% of Medicare dollars are spent on patients with 2+ chronic conditions. New programs, such as Chronic Care Management require a patient’s entire circle of care be able to access their information and communicate with that patient monthly. Our solution supports the delivery of CCM in a multitude of ways:
incorporate disease-specific care plans into our platform
- Deliver daily messages which compliment education + patient goals
- Deliver seasonal immunization reminders
- Break care plans into easy, micro-steps toward increased activity, improved diet, etc.
- Integrate patient diaries and biometric information into care manager and PCP follow-up
Condition-specific disease management including diabetes, heart failure and COPD.
Patients with chronic conditions have no help with the ongoing management of their disease. Medicare created the first payment program to incentivize doctors to provide support to these patients on an ongoing basis. Patients must receive at least 20 minutes of some form of communication a month to help them with med management, care plan review, health goals, education, etc.
Most providers don’t have the adequate technology or staff to deliver CCM in a cost-effective manner. A care plan has to be viewable by patients and specialist, added to and edited at least once a month and adequate documentation and reporting to ensure billed correctly and leaves a good audit trail. Most providers also do not think the monthly payment is enough to cover costs to them and end up using more expensive staffing resources then necessary. Compliance is also tricky as there are numerous components that must be bet on a monthly basis in order to receive payment.