Elements

Care Coordination Elements: integrated health + co-ordinated care

Remote Patient Monitoring

Telehealth is the future. As experienced through the recent COVID-19 crisis; remote care is no longer a future possibility for the healthcare space, but a necessity to maximize the experience for patients and healthcare professionals. Dr. Irina Koyfman has been building a Remote Patient Monitoring Implementation program unlike any other that will transform the continuum of care for patients, practices, providers and point of care.

RPM, done right, is the best way to increase your practice revenue, decrease hospital readmissions, along with increase patients’ satisfaction.

Remote patient monitoring (RPM) enables patients to remain at home while receiving optimal healthcare services to manage and treat their conditions, track signs of new symptoms, and intervene when needed.

The remote care program allows physicians to monitor patients' diabetes, heart disease, hypertension, cancer, weight gain, weight loss, and more.

Remote Therapeutic Monitoring Program

The Remote Therapeutic Monitoring program is part of remote monitoring and continues advancing the use of digital health tools to give healthcare professionals a more comprehensive data set of their patients’ health conditions.

Remote Therapeutic Monitoring (RTM) is a family of five CPT codes, including three Practice Expense (PE)-only CPT codes and two CPT codes that include professional work. RTM CPT codes are similar with Remote Physiological Monitoring (RPM) CPT codes. For example, the Remote Therapeutic Monitoring CPT codes reflect similar staff and physician work, although the specific equipment used is different because the data being monitored are non-physiologic rather than physiologic as they are with RPM.

Chronic Care Management Program

Chronic Care Management Program - is a critical component of primary care that contributes to better health and care for individuals. Centers for Medicare & Medicaid Services (CMS) acknowledged that less than 10% of Medicare fee-for-service beneficiaries presently receive ambulatory care management services. Therefore several important changes to expand access to these services were made... Read more at Chronic Care Management Program Consulting and Chronic Care Management Program Implementation

Care Coordination

Encompasses the oversight and education activities conducted by health care professionals to help patients learn to understand their condition. The work involves motivating patients to persist in necessary therapies and interventions and helping them to achieve an ongoing, reasonable quality of life.

Needs assessment for care coordination and continuing care coordination engagement
Care planning and communication
Facilitating care transitions (inpatient, ambulatory)
Connecting with community resources
Transitioning management

Care Coordination - deliberately organizing patient care activities and sharing information among all of the care team and the patient.

Community Health Worker Program

Community Health Worker (CHW) Program - CHWs bridge cultural and linguistic barriers, expand access to coverage and care and improve health outcomes.

Healthcare Leadership

Healthcare Leadership - being equally passionate, kind, smart, and humble

Patient-Centric Medical Home (PCMH)

Patient-Centric Medical Home (PCMH) - patient care is provided and coordinated through a primary care provider.

Recruitment and Retention of Healthcare Personnel

Recruitment and Retention of Healthcare Personnel - superb recruitment and retention strategy should be the priority of every healthcare leader.

Transitional Care

Transitional Care - are a set of actions designed to ensure coordination and continuity of care during patients transition from one place of service to another. Read more at Transitional Care Management Program Consulting and Transitional Care Management Program Implementation

Nursing Services

Nursing Services - coaching nurses about education, career path, business and more.