View
1
Download
0
Category
Preview:
Citation preview
Blueprint
YOUR STEP-BY-STEP
ROADMAP TO SUCCESSFULL
PHYSICIAN-PATIENT ENGAGEMENT
Through Lifestyle Medicine Care Coordination
Denise Campbell, MSPH, CHES
POPULATION CARE COORDINATION
1 Lifestyle Medicine
Lifestyle Medicine Care Coordination is the evidence-based practice of partnering with lifestyle practitioners in assisting individuals and their families to adopt and sustain behaviors that can improve their health and quality of life.
Exercise Nutrition Stress
Resilency Adequate
Sleep Avoidance of Tobacco
Moderation of Alcohol
Modifiable Components of Lifestyle Medicine
Scope of Practice
Health Problem
Determine Need
Partner with Integrative Health
Practitioners
•Certified Personal Trainers
•Certified Nutritionist
•Registered Dietitions
•Certified Health/Wellness Coaches
•Naturopathic Doctor
•Osteopathic Doctor
•Acupuncturist
Healthy At-Risk Pre-Chronic Chronic Disease
Stratified Population Engagement
Lifestyle-Related Risk – Risk for Progression – Risks for Complications – Risk to Quality of Life
Health Problem + Scope of Practice Diabetes = Massage for Edema & Lymphedema Diabetes = Glucose Control Exercises Diabetes = Diabetic Educator
Find Integrative Health Partners
Lifestyle Medicine Practitioners
All searchable in one cohesive platform
already credentialed & qualified to work
with your patients.
Chiropractor
Massage Therapist
Stress Management Experts
Financial Advisors
Faith-Based Organizations
Community-Based Organizations
Other Holistic/Integrative Modalities
The Institute of Lifestyle Medicine, Harvard Medical School
Partners
2
Referrals
POPULATION CARE COORDINATION
Direct Search By: Integrative Practitioner
Specialty
Geographical Area HEDIS Measures
Call In Concierge Services
Referral & Centralized Real-Time Scheduling
Identifies and focuses
on HEDIS gaps in care.
Prescribe Lifestyle
Medicine
Lifestyle Medicine
Information Exchange
Population Care
Coordination Services
Supports Achieving
Meaningful Use
Ability to Link with
Personal EHR
Never lose track of your
patients and have real-
time access to case
files.
All modalities are matched
with HEDIS measures to
ensure maximum revenue.
Our specialized care
coordinators can help
reduce ED visits and
readmission rates.
Our bi-directional
communication platform
allows patients and
families to fully engage
Outfitted with a backend
API to ensure full
integration of care plans
with a patient’s EHR
Patient Enrollment Physician Referral
Self-Referral Must have PCP involvement to continue
Scheduling/Appointments
Charting
Communication
Workflow Documentation Collaborative care tasks & workflow
Bi-directional communication with
entire care team, patients and their
families.
Centralized, real-time data and
charting that is integrated into one
electronic health record.
Billing and contract management
Referral Management
Integrative Practitioner In-Take Coordination
3 Collaborative Care
Patient Engagement
Treatment Plan
Treatment Tracking
Evidence Based
Behavior Change Strategies
Self-Management
SStrategies
Measure Outcomes
Report Outcomes
POPULATION CARE COORDINATION
As recommended by the attending
physician.
Bi-directional communication platform
that encourages patient initiation for
Meaningful Use measures.
PCP Dashboard IP Dashboard
Patient/Family
Dashboard
Patient
Primary Care Providers
Paper /Other
Offline Referral 3-Way Communication Meaningful Use
Integrative Practitioner
PCP Dashboard Components
“Brief Case Manager” SEARCH FOR IP BY SPECIALTY,
GEOGRAPHICALLY, OR BY HEDIS MEASURES
ACCESS TO ONLY THEIR PATIENT CASE FILES,
EMAIL AND COMMUNICATION COMPONENT.
REFERRAL & CENTRALIZED REAL-TIME
SCHEDULING
CASE FILES – INDIVIDUAL/FAMILIES/GROUPS
CUSTOM DEMOGRAPHICS
HEDIS MEASURES
CAPTURE ALL CORRESPONDENCE, CONTRACTS
AND APPOINTMENTS WITH CONSUMERS, PCP’S,
FAMILY MEMBERS, COLLEAGUES AND THIRD
PARTY PAYERS
INTAKE/REGISTRATION PROCESS AND CLIENT
ASSIGNMENT PROCESSES
CUSTOMIZE FORMS (IN-TAKE, TREATMENT
PLANS, SHIFT NOTES, SURVEYS, LETTERS, ETC.)
OUTCOME ASSESSMENTS (EACH IP AS WELL AS
AGGREGATE DATA FOR THE OVER-ALL
NETWORK)
SECURE EMAIL, ALERTS, NOTIFICATIONS,
WORKFLOW AND COLLABORATION TOOLS
WORKER PROFILES WITH SCHEDULING
AVAILABILITY
DIGITAL SIGNATURE CAPTURE
ACCOUNTS RECEIVABLE WITH FLEXIBLE SELF-
PAY AND THIRD PARTY BILLING INCLUDING
AUTHORIZATION TRACKING AND
INSURANCE/EAP BILLING (INTEGRATED 837 P
EDI CLAIM AND CMS – 1500 GENERATION)
INCLUDING CREDIT CARD PROCESSING.
iHealth Partners
Network Flow Chart
Make a referral Focuses on HEDIS gaps in service
Real-time access to patient lifestyle medicine cases
Recommended