Achieve Health Management

An End-to-End Health Care Solution for Patients and Providers

Contact Us Download App!

Achieve Health Management (AHM) provides patient monitoring and case management services to Skilled Nursing Facilities, Hospital Systems, Physician Groups, and Health Plans. AHM offers providers with affordable options by leveraging a highly skilled, multilingual and credentialed community-based workforce comprised of telehealth physicians, nurses, health coaches and case managers.

AHM medical experts will ensure that your Medicare patients’ health is closely monitored so they can maintain a level of health that will keep their chronic conditions from escalating.

Who is eligible?

  • Medicare beneficiaries with two or more chronic conditions
  • Patients with chronic conditions that place them at significant risk of death, acute exacerbation and functional decline

As Americans live longer, the growth in the number of older adults is skyrocketing to all-time highs, resulting in a highly taxed medical and behavioral healthcare system.

In 2014, 14.5 percent (46.3 million) of the US population was aged 65 or older

Adults 65 years or older are projected to reach 23.5 percent (98 million) by 2060.

In 2017, 65 percent of older adults managed 2 or more chronic conditions

Examples of Chronic Conditions:

  • Heart Failure
  • Stroke
  • COPD
  • Chronic Kidney Disease
  • Depression
  • Rheumatoid Arthritis
  • Parkinson’s
  • Osteoarthritis
  • Hypertension
  • Asthma
  • Myocardial Infarctions
  • Diabetes
  • Hip/Pelvic Fracture
  • Osteoporosis

Remote Patient Monitoring

According to europepmc.org: “The introduction of health information technology, including electronic health records and health information exchange, holds great promise for addressing many of the barriers to effective chronic care management, by providing important clinical information about the patient when it is needed, and where it is needed, in a timely, secure fashion.”

The AHM platform provides simple-to-use monitoring tools that are required to reduce inefficiencies, allowing your staff to provide high-quality care to more patients. AHM’s Remote Patient Monitoring system assists to quickly prioritize and triage patients who need it the most. AHM can even notify you on a preferred device if you have a high-risk patient with critical readings. The devices allow the Interdisciplinary Team (IDT) to respond with a well-choreographed plan of care 24/7. Whether your staff is based in-office or on-the-go professionals, we’ll give you the tools to improve collaboration and provide the best possible patient care.

Cinque Terre

Benefits of RPM

Cinque Terre

  • Provides actionable clinical data
  • Impacts costly emergency department visits
  • Reduces hospitalization and associated penalties
  • Permits dynamic collaborative interventions
  • Real-time data flow 24/7
  • Vitals signs are a click away
  • Data access via mobile devices (no Wifi necessary)
  • Impacts annual cost of care
  • Reduces family and caregiver fatigue

Data and Notifications

Unlike episodic providers, AHM manages and monitors discharged FFS patients – 6, 12, 24 months or longer, depending on their chronic conditions and IDT recommendations. Throughout this process we collect meaningful data that permits AHM clients to establish a partnership with the referral community. We also build a referral-centric network for the provider, which grows with each FFS discharge ultimately becoming a Q-Mix source.

  • Our Remote Patient Monitoring solution is simple for patients to use and highly versatile for our clients:
    • Requires no WiFi to send data to our team of health coaches and nurses to monitor
    • Sends notifications directly to designated stakeholders when preconfigured parameters are exceeded
    • Data may be accessed via our portal or an API constructed to push data directly to SNF EMR (Presently working with Cerner and EPIC hospital EMRs)
    • Notification of re-hospitalization is sent to all designated stakeholders (Capture Readmission)
    • Patients can review health information via our portal
Cinque Terre

WHO WE SERVE

HEALTHCARE SYSTEMS
  • Hospitals
  • Rural Health Care
  • IPA--Partial Risk
  • Accountable Care Organizations
  • Integrated Delivery Networks
  • Hospitalist Organizations
POST-ACUTE CARE
  • Private Duty Agencies
  • Certified Homecare Agencies
  • Residential Care Facilities
  • Assisted Living
  • Skilled Nursing Facilities
AT-RISK PROVIDERS
  • Physician Practices
  • IPA--Full Risk
  • Management Services Orgs
  • Physician-owned ACOs

SERVICES PROVIDED

HEALTHCARE SYSTEMS

  • AWV Verification & Completion
  • TCM Planning & Coordination
  • CCM Services
  • CoCM Services
  • MTM Services
  • RPM Services

POST-ACUTE CARE

  • AWV Verification & Completion
  • TCM Planning & Coordination
  • CCM Services
  • CoCM Services
  • MTM Services
  • RPM Services

AT-RISK PROVIDERS

  • AWV Verification & Completion
  • TCM Planning & Coordination
  • CCM Services
  • CoCM Services
  • MTM Services
  • RPM Services
Cinque Terre

BENEFITS FOR ALL

  • Longitudinal vs. Episodic Cost Savings
  • Reduction of 30-day readmissions penalty avoidance
  • AHM Data Aggregation community-facing HIE
  • Eliminates Redundant Services Rapid triage
  • Risk Stratification Machine learning
  • Improved HCCAP Scores/QAPI (Hospital and Skilled Nursing Facility) Patient and family satisfaction
  • Community Referral Expanded footprints
  • Network Patient Retention Monitoring 6, 12, 24 months

The Centers for Medicare and Medicaid Services Programs and Services

Chronic conditions negatively affect the quality of life and contribute to death among this frail elderly high-risk population. In order to more effectively manage the growing demands of this frail population, The Centers for Medicare and Medicaid Services (CMS) has established a series of comprehensive programs that focus on proactive Chronic Care Management.

Annual Wellness Visit (AWV): Medicare now covers an AWV with their physician at no cost to the patients, whether they are enrolled in original Medicare or a Medicare Advantage plan, as long as they receive the service from an in-network provider. This visit is an opportunity for the patients and their doctors to develop a personalized prevention plan that will take a comprehensive approach to improving their health and preventing disease.

Transitional Care Management (TCM): TCM refers to the coordination and continuity of health care during a transition from one healthcare setting to either another or to home (Care Transition) if another facility is needed to address any changes in condition or care.

Chronic Care Management (CCM): CCM offers additional help managing chronic conditions like arthritis, asthma, diabetes, hypertension, heart disease, osteoporosis, and mental health, to name a few. This includes a comprehensive care plan that lists their health problems and goals, medications, community services they have and need, and other information about their health. It also explains the care they need and how their care will be coordinated.

Collaborative Care Management (CoCM): CoCM is a highly focused model for delivery of behavioral health services, designed to enhance “usual” primary care by adding two key services: care management support for patients receiving behavioral health treatment, and regular psychiatric interspecialty consultation to the primary care team (particularly regarding patients whose conditions are not improving).

Medication Therapy Management (MTM): MTM is a patient-centric approach to optimize medication use, reduce risk of adverse events, and improve adherence.

MTM areas of concentration include:

  • Comprehensive Medication Review (CMR)
  • Medication Action Plan (MAP)
  • Targeted Medication Review (TMR)
  • Personal Medication List (PML)

Remote Patient Monitoring (RPM): RPM is a rapidly evolving technology which enables the monitoring of patients outside of conventional clinical settings thus increasing access to care and decreasing healthcare delivery costs. Incorporating RPM into chronic disease management can significantly improve an individual's quality of life.

Typical vital signs monitored by RPM include: Blood Pressure, Pulse Oximetry, Weight, Glucose Levels and Temperature

Our Health Experts and Enrollment

“Almost all healthcare leaders surveyed believe chronic care management is essential, but nearly half don't think their facilities are managing chronic care or preventing hospitalizations very well.”
www.healthcaredive.com

Achieve Health Management provides case management and monitoring services to Skilled Nursing Facilities, Hospital Systems, Physician Groups, and Health Plans. We supply providers with affordable options by leveraging a highly skilled, multilingual and credentialed community-based workforce comprised of:

Health Coaches

Case Managers

Triage Nurses

Telehealth Physicians

Nurse Practitioners

24/7 Call Centers

Our call centers are managed and monitored by the AHM team of compliance officers who ensure that we meet the strict standards established by The Centers for Medicare & Medicaid Services (CMS). Our coaches and clinical staff follow detailed protocols developed by AHM as well as the integration of client-specific care plans. Unlike a standard answering service, our nurses play a proactive role in triaging the incoming clinical and mental health need(s).

Nurse Triage and After Hours Calls

Unlike a standard answering service, AHM nurses answer calls from clients and then triage the call depending on the urgency. Calls are addressed with the provider’s specific clinical protocols or, if needed, escalated (SBAR) to the Nurse Practitioner or Physician on call.

Chania

Seamless Patient Transition to Community

Achieve Health Management provides a closed loop solution to ensure each Fee for Service (FFS) discharge is well-choreographed and meets the unique needs of the patient. Unlike solutions that place a cost burden on the SNF, we have developed a self-funding discharge model which draws on a series of Current Procedural Terminology (CPT) codes:

TCM: Transitional Care Management

CCM: Chronic Care Management

CoCM: Collaborative Care Model

MTM: Medication Therapy Management

BHI: Behavioral Health Integration

RPM: Remote Patient Monitoring Key Vital Signs

Telemedicine Primary Care Nurse Practitioner

Home Visit Nurse Practitioner Social Worker

Annual Wellness Visits – Initiating SNF Discharge Process

In order to leverage the CPT Codes, AHM must first verify that an Annual Wellness Visit (AWV) has taken place in the past 12 months. By utilizing our proprietary software, we can quickly access the information to determine AWV status. In the event an AWV is required, we recommend the following:

  • TCM-99495 covers communication with the patient or caregiver within two business days of discharge. This can be done by phone, e-mail, or in person. It involves medical decision-making of at least moderate complexity and a face-to-face visit within 14 days of discharge. The location of the visit is not specified.
  • TCM-99496 This can be done by phone, e-mail, or in person. It involves medical decision-making of high complexity and a face-to-face visit within seven days of discharge. The location of the visit is not specified. It covers communication with the patient or caregiver within two business days of discharge.

Education and Enrollment

Patients are educated on the various CPT Codes prior to being discharged from the facility. Based on the clinical or behavioral demands, a unique set of programs are selected for the patient’s pending discharge. This information is provided to AHM in advance and the patient encounters are initiated in the community as well as telephonically upon discharge.

CCM includes:

  • An electronic summary of the physical, mental, cognitive, psychosocial, functional, and environmental assessments
  • A record of all recommended preventive care services
  • Medication reconciliation with review of adherence and potential interactions and oversight of patient self-management of medications
  • An inventory of clinicians, resources, and supports specific to the patients, including how the services of agencies or specialists unconnected to the designated physician’s practice will be coordinated.

CoCM: Psychiatric Collaborative Care Model (CoCM) is an approach to BHI and is shown to improve outcomes in multiple studies. What is CoCM? A model of behavioral health integration that enhances “usual” primary care by adding two key services: care management support for patients receiving behavioral health treatment and regular psychiatric interspecialty consultation to the primary care team, particularly regarding patients whose conditions are not improving.

MTM: Providers work with physicians to deliver the best medication therapy to patients and to coordinate their medication therapy across multiple practitioners. The latest clinical information is used by MTM providers when reviewing patients’ medication therapy, such as updates to the Beers criteria for high-risk medications and revised monographs for old and new medications. MTM providers also listen to patients’ concerns about their medications and may offer recommendations to physicians and patients to help achieve their goals of therapy.

BHI: Behavioral Health Integration includes core service elements such as systematic assessment and monitoring, care plan revision for patients whose condition is not improving adequately, and a continuous relationship with a designated care team member. It may be used to report models of care that do not involve a psychiatric consultant or a designated behavioral health care manager (although such personnel may furnish general BHI services).

RPM:

  • Blood Pressure
  • Pulse Oximetry
  • Thermometer
  • Scale
  • Glucometer
  • Telehealth

Testimonials for Chronic Care Management

Karen L. Smith, MD, FAAFP shares her experience with offering Chronic Care Management (CCM) services to her Medicare patients in a rural North Carolina community. Watch this short video to learn more about the benefits of providing CCM to patients living with multiple chronic conditions. Visit go.cms.gov/ccm to learn more about the Connected Care campaign and get resources you can use to educate your patients about CCM.

The CMS Office of Minority Health and the Federal Office of Rural Health Policy (FORHP) at the Health Resources and Services Administration (HRSA) hosted this webinar on March 15, 2017 to inform their partners of the benefits of Chronic Care Management services and the Connected Care.

Hattiesburg Clinic offers two additional services to Medicare patients through the Quality Management Program: Annual Wellness Visits (AWV) and Chronic Care Management.

Mayo Clinic cardiologists and engineers are developing technology to remotely monitor patients. This technology has the ability to impact the science of healthcare delivery world-wide. To learn more about remote monitoring at Mayo Clinic, visit http://www.mayoclinic.org/departments.

Contact Us





2211 Encinitas Blvd. Suite #200 Encinitas, CA 92024


Achieve Health Management LLC Las Colinas The Urban Towers 222 West Las Colinas blvd. Suite 1650 Irving TX 75039

Download Our App

Available on App Store for iOS devices and Google Play Store for Android devices

AHM app is free to download!

Download AHM onto your iPhone, iPad or iPod Touch Download AHM onto your iPhone, iPad or iPod Touch
Chania