Bob and Mary Part 1 explained the different needs for Bob, a critical Medicare patient, and Mary, a chronic-but-stable Medicare patient. It can be just as challenging for practices to physically manage the Marys as it is the Bobs, in addition to the Medicare reimbursement management.

CareTrack’s continuous care model supports chronic-but-stable Medicare “Mary” patients by enabling better care and better resource utilization. This approach leads to an improved quality score and high reimbursement revenues for practices.

What is Telecare and why is it important? Telecare follows patients in-between the telemedicine or in-person appointments. When done correctly, Telecare turns the routine patient care-coordination model into a super-charged continuous care model. Telecare enables improved patient support and frees up nurses to optimize care plans and to assist patients. Telecare is reimbursable from Medicare, so it benefits both patients and practices’ revenue-model.

How does CareTrack’s Telecare Team interact differently with patients? To help you learn more about CareTrack’s Telecare experience, we want to introduce you to ‘Remote Rhonda.’ She is a Care Team Coordinator at CareTrack, whose job includes interacting with Medicare patients by calling them throughout the month and before their telemedicine or in-person appointments. She knows many of her patients by name and notices small changes in their health. Her patients are thankful for her help and look forward to these phone calls. While the in-office team address more immediate and critical patient needs, Rhonda makes patients feel heard.

Rhonda sees many couples like ‘Bob and Mary.’ The standard care model gives more of the practice’s attention to Bob since he is considered critical. Mary serves as Bob’s primary caregiver, but her health is steadily declining, even though she remains chronic but stable.

During the monthly outreach calls, Rhonda speaks with patients about their surgical history, social history, emotional state, family history, medications, and discusses instructions from the doctor, changes in medication, and adds records from other doctors or specialists to the patients’ charts. 

How does Rhonda provide more continuous support than a typical practice care coordinator? CareTrack’s managed telecare system compiles all of the critical care plan requirements from the chart and prepares a summarization that enables the care coordinator to connect the dots. The system automatically applies charting information from calls and updates specialists’ notes while tracking patient vitals against physician-set thresholds. 

You have a better informatics product. How does that translate into continuous care? The care plan allows the physician to define remote patient monitoring thresholds integrated with the patient adherence program to reconnect the dots. Utilizing CareTrack’s technology, Rhonda knows exactly which patients and Care Plan to review during each call. Rhonda gathers data from patients’ at-home blood pressure machine and glucometer to check for further action. Quick updates and periodic summaries are sent to a patient’s provider when needed.

Our nurses know our patients. How would you be able to duplicate that relationship? We are not a replacement for nurses, rather an extension of your team. Since our focus is on current chronic-but-stable patients, we get to know the patients and practice staff over time and build long-term relationships. Our high retention and patient satisfaction rates speak for themselves.

In many cases, one spouse puts all of his/her needs aside to care for his/her loved one. Because of this, it is important that Remote Rhonda encourages and provides care to both the critical and the chronic but stable patients during in-between doctor visits.

CareTrack’s 24/7 Care Line allows Rhonda to monitor Bob and Mary all day, every day. In addition, Rhonda helps Bob and Mary adhere to their doctors’ structured, comprehensive care plans. She ensures they understand the physician’s recommendations and their individualized care plans. 

Rhonda can view Mary’s recent appointment history and schedule an AWV with a note to review her medication since a significant amount of time has passed. Rhonda can also view RPM thresholds specific to each patient and review Mary’s last 10 readings and discover Mary has a lower RPM threshold than someone else her age and is beyond the threshold defined by her doctor. Rhonda can also update Mary’s care plan and chart based on her new medications from Mary’s last specialist appointment. All of the changes in Mary’s health condition would not have been caught with the standard care coordination, and Rhonda will be able to help Mary get her health back on track.

How much will it cost our practice out of pocket? Nothing. We bill through the practice and utilize many of the Medicare billing codes that most practices don’t adopt across their practices. This actually will create a much greater revenue stream for the practice. 

We won’t do anything unless it also helps our patients. How does this benefit them? Patients enjoy the continuity and frequency of care. This model allows nurses to have more impactful interactions with patients, improving the overall quality of care and higher quality scores. 

The comprehensive and proactive approach provided by CareTrack’s Telecare solution benefits critical patients, chronic but stable patients and the practice. CareTrack’s Care Team Coordinator, ‘Remote Rhonda,’ ensures that Mary manages Bob’s condition and ensures that one of Mary’s small health issues does not spiral into a more critical health condition before her doctor is aware.

Learn how CareTrack’s Telecare Team can ensure continuous care of both critical and chronic but stable Medicare patients today, at no cost to the medical practice.  

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