A database will be created with user logins for the client. Eligible Patients will be identified by the client’s EMR, exported and uploaded in Synergy Care Management’s data base. Many EMRs allow for the identification of Medicare patients and further filter for ICD 10 codes. However, this may miss many prospective patients with non-traditional chronic conditions. Synergy Care Management’s staff will access and review the medical records of the client’s EMR to ensure no lost eligible patients.
All eligible patients will be called and enrolled into Synergy Care Management’s concierge service. Patient consents will be obtained and documented in the portal consistent with Medicare guidelines and regulations. We suggest a written consent be obtained during the routine clinic visits to further ensure compliance, although this is not required as verbal consent is sufficient for enrollment per CMS regulations.
All patients will be contacted to create new care plans, and these care plans will be tracked monthly. Patients will be assessed for a host of factors, including but not limited to allergies, medication compliance and side effects, lab testing, ancillary service scheduling, referral management, barriers to care, fall risk, etc. We advise the Synergy Care team to use the patient portal to document all interactions with the patient, such as medication refills, referral management, and lab review, to satisfy Medicare time guidelines further. Providers and their staff routinely provide more than 60 minutes of uncompensated care management which Synergy Care Management can now guarantee that time spent working towards patients’ health goals is not overlooked and also reimbursed.
All care plans will track evidence-based guidelines for outcome measures. These can be further modified in collaboration with the patient’s provider. Alerts and patients can be flagged for varying degrees of risk and the on-site care team can be notified of a problem or deviation from the care plan. Furthermore, additional referrals and ancillary services might be warranted to ensure compliance with the care plan.