Assign a care coach to coordinate care among the office, the referral sources, facilities, pharmacy, home health agency and family.

Provide at least quarterly pain assessment, fall risk, depression score, hospitalization risk & mortality assessment.

Care transition follow up at all levels including specialists, rehab, hospital or any pertinent transfers.

Access to resources like educational materials, disease education, smoking cessation and other community service access.

Referral management after it is sent by office.

Monthly POA call on your behalf if applicable.

Help with patient assistance programs / prior auths / any other needs of the patients.

Provide HEDIS measures / ACO goals review with patients monthly as needed.

Perform bi-annual MRA assessments.

Assess med effectiveness, adverse effects and continued need of antipsychotics, sedatives and antidepressants.

Assess for new symptoms if identified through CCM or provider.

Facilitate and coordinate treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation or treatment assessment.

Blood pressure

Pulse

Pulse oximetry

Weight

BGL

Patients with:

Hypertension

Heart Failure

Diabetes

Prediabetes

Chronic Kidney Disease

COPD

Obesity

We custom design your needs on the above and work month after month on enrolled patients to ensure completions, record tracking and meet quality. It’s part of our service with no additional cost to you.

We start with the enrolled patients after the second month of going alive with our program and will be revisited every 6 months. This allows the practice to identify all the conditions that can be prevented from progressing as well monitor a lot more aggressively. This is also where you can sustain value based contracts and cost savings. It’s part of our service with no additional cost to you.

We offer this through 3 channels :

Through our assigned care managers to the patient – They follow up with the patient from home to hospital to rehab to home.

Through our integrated partner who can provide NP to visit patient homes after each exacerbations and transition.

Successfully proven paramedic home visit program through our integrated partner.

Baba LTC offers this through 2 channels :

Through our assigned care managers to the patient – Who work with patients and their POA in addressing all their needs

Through our state of the art integrated technology that allows you to create your own healthcare network that allows HIPAA compliant referral coordination and messaging.

By improving provider network contract performance.

By increasing person centered in-network , coordinated care to deliver higher quality by our integrated technology , care coach , third party and provider integrated network and in home NP services for transitions and high risk individual.

By restoring financial stability.

By preparing for value-based contracts.

By diversifying revenue across service locations and

By delivering improved patient and provider experiences.

Once we enter into our official contract and HIPPA agreement we will become part of your organization as contracted employees. From the time of signing contracts to really start CCM takes roughly 1 month :

Step 1 – We will work with the office manager in pulling the list of patients with 2 or more chronic conditions and their contact info from the EMR to an Excel sheet and create enrollment and custom CCM workflow for your office addressing all your needs .Each practice will have a cheerleading office manager and a lead MA for patient needs for STANDBY and office communication purpose only. We will also have access to your practice EMR to access patient records and for communication purposes.

Step 2 – We will contact the patients through Phone calls on behalf of the practice and explain the practice intention with CCM and how together we become their healthcare coach and care coordinators and enroll them into the program.

Step 3 – When all eligible patients are contacted and enrolled we will initiate the CCM and give the practice the list of patients enrolled and list of patients not enrolled. The practice can work with non enrolled patients to enroll them.

Step 4 – At the beginning of each month the prior calendar month’s billing episodes of that month, with uploaded supporting documents in their EMR, are given to practice along with our fees.

Step 5 – The practice bills insurances for those episodes and gets paid and pays us for the contracted consultant fees we agreed upon with in 30 days of billing cycle

Once we enter into our official contract and HIPPA agreement we will become part of your organization as contracted employees. From the time of signing contracts to really start RPM takes roughly 1 month. In addition to Medicare, Medicare HMO’s, many commercial insurances participate as well :

Step 1 – Here our CCM identifies RPM needs or a provider can refer and create enrollment into the RPM program. Each practice will have a cheerleading office manager and a lead MA for patient setups and office communication purposes only. All the equipment will be mailed to you for standee, your team will educate the setups, which is billable time. We will train the staff on set ups.

Step 2 – All threshold values to alert provider and patient can be customized as per provider. We will monitor and contact the patients through Phone calls on behalf of the practice and understand why the readings are abnormal and update the provider. Once providers response obtained, we will keep patient informed of the instruction and closely follow them

Step 3 – Based on the conditions their remote patient monitoring initiated we then initiate care pathways that will track the progress at least bimonthly.

Step 4 – At the beginning of each month the prior calendar month’s billing episodes of that month as well monthly equipment fee with uploaded supporting documents in their EMR, are given to practice along with our fees.

Step 5 – The practice bills insurance for that and gets paid and pays us for the contracted consultant fees we agreed upon within 30 days of billing Cycle.

Once we enter into our official contract and HIPPA agreement we will become part of your organization as contracted employees. From the time of signing contracts to really start BHI takes roughly 1 month. In addition to Medicare, Medicare HMO’s, many commercial insurances participate as well :

Step 1 – Here our CCM identifies BHI needs or a provider can refer and create enrollment into the BHI program. Each practice will have a cheerleading office manager and a lead MA for patient office communication purposes only.

Step 2 – All threshold values to alert provider and patient can be customized as per provider. We will monitor and contact the patients through Phone calls on behalf of the practice and assess the effectiveness of meds or disease using custom care pathways. We notify providers of any above or below threshold value and once a provider’s response is obtained, we will keep the patient informed of the instruction and closely follow them . These patients need that extra support to cope and we become their cheerleaders.

Step 3 – At the beginning of each month the prior calendar month’s billing episodes of that month as well monthly equipment fee with uploaded supporting documents in their EMR, are given to practice along with our fees.

Step 4 – The practice bills insurance for that and gets paid and pays us for the contracted consultant fees we agreed upon within 30 days of billing Cycle.