Annual Wellness Visits
An Annual Wellness Visit (AWV) consists of a robust set of patient-centered health information: demographics, objective parameters, labs, preventative health screenings, and vaccine history. We contact the patient for an in-person, one-on-one visit. This information is used to create a health risk assessment for chronic health conditions. Lastly, we create a patient-specific 5-year care plan for disease state prevention and management.
Chronic Care Management
Chronic Care Management (CCM) is a monthly patient check-in system designed to allow for more touch points with the patient. Our team will make multiple calls each month to verify how your patients are handling their chronic medical conditions. Topics typically covered are: medication adherence and education, resolving drug therapy problems, triaging health concerns, and ensuring patients are completing their preventative health screenings and vaccinations.
Remote Physiologic Monitoring
Remote physiologic monitoring (RPM) is a service to utilize and integrate technology into chronic patient care. We provide patients with devices such as: blood pressure monitors, pulse oximeters, blood glucose monitors, and scales all equipped with cellular capability to transmit physiologic data in real time. This will allow us to gather more data points and see the dynamic clinical picture, which will allow for robust patient-centered care.
Behavioral Health Integration
Behavioral health integration (BHI) is a subset of chronic care management related to helping your patients manage their mental health conditions. This service is structured as multiple touch point check-ins via phone, to address and questions and concerns related to mental health patient care.