Risk-Based Population Management System
Our comprehensive risk stratification system empowers you to better understand and manage your patient population, deliver targeted interventions, improve care coordination, and measure performance accurately and efficiently. PCM’s analytical tools can provide valuable insights into patient populations, care coordination, utilization management, and performance monitoring for your organization.
By leveraging these tools effectively, you can enhance the appropriateness of services, improve patient outcomes, and optimize resource utilization within your network and population.
Combining Medicare claims data with our proprietary analytics enables us to identify high and rising risk patients in your population and provide worklists that will allow you to prioritize your activity with patients and take advantage of preventative and interventional care opportunities. Our analytics tools assist you in identifying the right candidates for managed care services such as CCM, RPM, Home Health, and Hospice, allowing you to stay engaged with your high-risk patients even when they aren’t in the clinic.
Identification and Care Management Intervention Team
PrimeCare’s Case Managers actively send reports and status updates to aid physicians in making informed deci- sions about the level of care needed, the frequency of visits, the inclusion of specialized services or therapies, and the monitoring requirements for specific conditions. Care management involves implementing the physician’s care plan among home health nursing staff, patients, and caregivers. This includes regular updates, sharing of infor- mation, and addressing any concerns or questions. Efficient communication consists of the following care team collaboration: • Nurse Practitioners Televisits / Home Visits • Certified Wound Care RNs • Field Nurses • Case Managers • QA Managers
Identification and Care Management Intervention Team
PrimeCare’s Case Managers actively send reports and status updates to aid physicians in making informed decisions about the level of care needed, the frequency of visits, the inclusion of specialized services or therapies, and the monitoring requirements for specific conditions. Care management involves implementing the physician’s care plan among home health nursing staff, patients, and caregivers. This includes regular updates, sharing of information, and addressing any concerns or questions. Efficient communication consists of the following care team collaboration: • Nurse Practitioners Televisits / Home Visits • Certified Wound Care RNs • Field Nurses • Case Managers • QA Managers
Monitor & Reduce Acute Care Encounters
Identifying patients with frequent acute encounters is essential for optimizing resource allocation, containing costs, improving patient outcomes, facilitating personalized care plans, and enabling effective population health management.
Our analytics tools aid you in this process, enabling you to focus more effectively on these patients to provide more efficient, proactive, and tailored care, leading to better health outcomes for individuals and the population as a whole.
(RPM) Remote Patient Monitoring
By leveraging remote monitoring technologies, PrimeCare can closely monitor patients’ health conditions, detect early warning signs, facilitate timely interventions, and empower physicians with out-of-parameter alerts and virtual dashboards. These interventions can help prevent exacerbations, complications, and hospital admissions, ultimately improving patient outcomes and reducing healthcare costs. Physiological data reports and alerts are shared with physicians daily, weekly, or monthly.
Medication Compliance
PrimeCare’s Medication Reminder Program offers numerous benefits, including improved medication adherence, prevention of missed doses and medication errors, increased treatment effectiveness, better disease manage- ment, reduced hospitalizations, emergency visits, peace of mind, and enhanced independence. Reminders are sent to patients via mobile (SMS) text messages, and responses can be logged confirming patients followed their prescribed regimen or were non-compliant.