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?
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:
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.
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.
BENEFITS FOR ALL
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:
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
“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:
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.
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:
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.
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).
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.