chronic Care Management
Chronic Care Management
Better Patient Health – Better REIMBURSEMENT Rates
Patients, caregivers and staff are all important elements of your practice.
H3C has a simpler approach to Chronic Care Management that allows you to make patients’ lives better through regular communication between visits. Patients feel secure, heard, and respected. Caregivers and patient advocates are more up-to-date with the patient’s health, providing peace of mind. Staff workload is lightened allowing them to focus on the most critical patients.
New To Chronic
Care Management (CCM)?
CCM is the care management of patients with two or more chronic conditions (asthma, diabetes, hypertension, etc.). To qualify for reimbursement a minimum of 20 minutes must be spent monthly on care coordination services which include tasks like patient outreach, medication reconciliations, and records collection.
Our clinical care teams will use our dialer and technology platform to proactively reach out to patients to engage them in their wellness and to provide the necessary services and documentation required to meet the 20 minutes per month.
Our clinical teams include licensed RNs, LPNs and CNAs. All of our staff are licensed in the state in which the patients reside to comply with state and federal regulations.
Our care teams are dedicated to your facility, meaning your patients won’t speak to different people each time we call, or they call in. Our team is accessible to patients at all times including 24/7 triage capabilities.
Optimizing the Chronic Care Experience
Maria, our proprietary platform, provides your patients with more than a monthly phone call. She provides trust, compassion and care. This proactive solution is a simple way for you to keep your practice running smoothly day-to-day; while Maria assumes the burden of the monthly patient calls and documentation so that you receive maximum reimbursements.
The Maria Difference
⊕ Maria captures data points objectively and discretely allowing patients to be automatically presented according to priority
⊕ Patient-centric Care Plans are customized to individual patient’s needs, dynamic…changing as the patient’s needs change
⊕ Our proprietary risk stratification, prioritizes patients by risk level allowing you to be efficient with follow-up conversations
⊕ Quality measures are incorporated into care plans helping your practice maximize reimbursements
⊕ Flexible and dynamic, Maria’s clinical pathways, workflows, and assessments are customizable to individual clinic’s needs
⊕ Integrated AI detects patient anomalies by comparing assessment responses to preset thresholds triggering automated team alerts
An existing patient described being disoriented and could not remember large blocks of time. The patient’s dedicated H3C nurse triaged the patient and identified that the patient was currently oriented x3. The Nurse immediately contacted the doctor for a same day visit. The doctor identified the patient had experienced a stroke. Due to social isolation the patient unfortunately had no one identify this during the event. The physician developed a treatment plan for prevention and the H3C team assisted the patient with overcoming his social isolation through locating appropriate community involvement opportunities.
An H3C care team member was reaching out to a patient to schedule an Annual Wellness Visit. The patient was very upset with news of a new disease. The care team member explained the benefit of continuum of care with CCM. The conversation provided the patient with much needed support and guidance at a time when they otherwise felt very lost. The H3C team member provided education on their disease along with community resources. More importantly they provided an ear to the patient who very much needed just to talk with someone who would listen. The annual visit was scheduled and the patient requested CCM services just as the physician was recommending them.