Our Services
CHMS focuses on preventive medicine for the most vulnerable patient population.
These services include Chronic Care Management and Remote Patient Monitoring.
Chronic Care Management
CCM is a service that requires spending at least 20 minutes each month on the resident's behalf managing and monitoring their chronic conditions. This could include the following services:
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Medication Reconciliation
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Chart Review
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Care Plan Creation, Support, and Management
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Resident, POA, and/or Care-Giver monthly communications
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Coordinating with community and social support services
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Transitional care management services
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Communication with the Medical Director monthly to help fill gaps in care
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Monitoring and flagging any changes in resident conditions to ensure preventive and proactive measures are in place
Benefits of CCM
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Proactive approach to filling the health gaps in resident/patient care
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Collaboration with Medical Director and Care Team to provide preventative medicine
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Reduction in Unnecessary Emergency Room Visits, Hospitalizations, and Readmissions
Remote Patient Monitoring
Qualifications:
All Medicare and Medicare Advantage insured residents ​
All residents with chronic and/or acute conditions that can be monitoring through a remote health monitoring device
such as (but not limited to):
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Diabetes​
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Hypertension
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Hypotension
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Asthma
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Obesity
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Congestive Heart Failure
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RPM is a voluntary program and requires consent from each resident or resident's POA
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Residents must utilize a device to monitor the data for their conditions at minimum 16 times per month
and the device must have the ability to wirelessly transmit data to a platform for real-time review by Care Coordinator
​RPM is a monthly service that requires:
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Resident consent
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Initial device set-up and resident education on utilization of device
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Device utilization of at least 16 times per month by each resident
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At minimum 20 minutes of resident time spent monthly: reviewing transmitted data from residents, interacting with resident, medical director and care team
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Monitoring and flagging any changes in residents vitals and/or data trends to assure preventive and proactive measures are in place
Benefits of Service:
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Proactive approach to filling healthcare gaps in resident care
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Collaboration with Medical Director and Care Team to provide preventative medicine
-
Reduction in unnecessary emergency room visits, hospitalizations, and readmissions
