How we work with your patients
Step 1: Inform patients of your CCM program
We identify patients who qualify, notify them with a postcard, andfollow up with an enrollment call.
Step 2: We talk to your patients each month
Enrolled patients receive monthly phone calls from their dedicated H3C representative who understands theircurrent medical challenges. Calls are personalized and focus on patient’s changing needs helping them overcome barriers to their care.
Step 3: We report back to you
We integrate patient assessments from each call directlyinto your existing EMR system in real time. Your providers have more constructive conversations with their patients during office visits because they have more comprehensive information about the patient’s health.
More than a follow-up call
Our monthly calls are never the same! Our calls are problem specific; they’re tailored to—and respectful of—each individual patient.
How we collaborate with you
We collaborate with your clinical champion to match your workflows and collect system-specific information critical to understanding your patients and community.
When we see patients showing declines, slippage, or issues, we flag the case for review by an H3C nurse supervisor. All changes are passed along to the designated champion.
After a baseline is established, we develop a customized care plan for each patient.
Our team provides risk stratification reporting that will provide you with a monthly snapshot of your Medicare population.
Your H3C Support Team
Getting started with us is easy
All you need to do:
Provide a list of your eligible Medicare patients
We’ll reach out to your Medicare patients suffering from two or more chronic conditions and work to enroll them in the CCM program.
Grant us remote access to your EMR
Our proprietary workflow integrates with your EMR to keep your records updated with all communication and patient data provided on your behalf.
Assign an internal champion
Assign someone from your team as the primary point of contact for periodic program updates.
We’ll do the rest
• Confirm patient eligibility and build out cohorts
• Schedule and conduct orientation sessions with your staff
• Create marketing materials
• Build out clinical pathway and care templates
• Craft encounter note summary templates
• Confirm program update process
• Send out welcome letters to patients
• Conduct EMR assessment
• Coordinate patient introductions
• Obtain and document patient consent
• Ensure compliance standards are met
• Connect with patient caregivers
• Complete intake assessment
• Conduct monthly patient calls, assessments, and pathways
• Review and update patient goals
• Carry out intervention plans
• Coordinate in-person patient appointments
• Provide referral assistance as needed
• Generate and upload care plans to EMR
• Mail care plans to patient
• Upload post-encounter summary notes
• Submit monthly risk level report
• Generate productivity reports
• Compile monthly billing reports