Proactive Healthcare – Is Telehealth Helping Your Patients, Practice and Medicare?

I so believe in Medicare’s program that I thought what better way than to share some stories with you.

Our certified care manager performed her regular phone call to the patient, whom had a history of strokes. During our conversation, we realized that the patient was exhibiting signs of stroke. Upon encouraging her and speaking directly with the physician, we were able to expedite medical care. We learned that the patient did not have a stroke, thank goodness. The patient was diagnosed with a brain tumor. When we reached her a month later after her hospitalization and treatment, she expressed such gratitude that we kept checking on her until she sought treatment.

We have similar stories of helping the patient who was taking the wrong dosage of insulin or the patient with glucose level over 500 mg/dl. Another recent situation was a patient with radiating left arm pain with chest pressure when we called. We believe our immediate intervention helped prevent more serious consequences. Would you not want to be notified sooner if there is a change in your patient’s healthcare status?

Patient satisfaction improves because patients even call our care managers to help them schedule appointments and be a liaison for the physicians. Patients feel that their physicians are aware of health care, medication or other changes since their last face-to-face visit with their physician. This program is helping to coordinate their medical information across all of the patient's different physicians by sharing knowledge. Their family members and the patients thank the care managers and physicians for the doctor’s oversight.

How are we doing this? Our care managers are calling Medicare patients with two or more chronic conditions every month following other guidelines by Medicare. Our staff is helping to schedule appointments to allow patients to be seen sooner if needed. They are creating monthly care plans coordinating with the patient and doctor. Our care managers help set individualized monthly goals for every patient and confirm adherence to the goals from the previous month. They investigate if there are barriers to obtaining goals and follow up as needed, as evidenced by the persistent care manager identifying the status changes in the brain tumor patient.

In 2016, Medicare established Chronic Care Management with the goal of reducing medical costs by driving down hospitalization costs. Medicare believed and supporting studies showed that this would occur. Medicare’s publication in February 2018 reinforced those findings: https://innovation.cms.gov/Files/reports/chronic-care-mngmt-finalevalrpt.pdf

Contact me if you would like your patients enrolled in this innovative program that improves patient engagement and satisfaction, helps drive down medical costs, improves patient and physician communication, meets some MACRA initiatives and increases practice revenue. We are happy to demonstrate the Chronic Care Management program to you.

Diane Schultz

[email protected]