Our services are aligned with the Centers for Medicare and Medicaid Services (CMS) and Health and Human Services (HHS). They provide opportunities to outpatient and hospital primary care physicians for managed coordinated care, which will render the best care for our patients, and cost savings for our providers. Below are the aspects of health care we support, and the initiatives and organizations we have unified with.
Led by a robust and seasoned team of administrative health care professionals, as well as Medical Director Dr. Humberto Fernandez-Miro and Clinical Director APRN Antonio Sanchez, the organization is primed to pioneer the space of home care, interoperability and care planning. Combined, the leadership of CCMS brings over 100 years of experience in the industry.
Medical Director Dr. Humberto Fernandez-Miro
Benefit for Physicians: What Benefits the Patient Also Benefits the Provider
By employing the various services offered, physicians will be able to organize patient record files to be as comprehensive as possible, drawing information from multiple physician practices, hospitals and SNFs, as well as through our remote patient monitoring and multi-faceted telemedicine. This allows physicians to develop optimal, coordinated care plans for their patients, which not only increases revenues by qualifying physicians to use coordinated care CMS benefits, but also reduces patient re-admissions, a central focus for CMS. Most importantly, reduced re-admissions and a coordinated care plan based on comprehensive patient history will result in the best patient care possible.
This Re-Admission Reduction Program is currently for SNFs, but it would translate to hospitals. As of October 1, 2018, SNFs would also be penalized if re-admissions occur. The Affordable Care Act has increased the incentives for acute care systems to work closely with post-acute providers. Incentives to reduce hospital and SNF length of stays, combined with an overall commitment to improvement of patient outcomes generated from a basic alignment with post-acute providers, pushing the reduction of re-admission penalties, with value-based purchasing, and risk-based payment models such as bundled payments and Accountable Care Organizations (ACOs), have raised the importance of post-acute alignment.
Post-Acute Care, Re-Admission Reduction Program (Skilled Nursing Facilities and Hospitals)
We provide Transitional Care Management (TCM), in our re-admission reduction program as well as, our group practice program. Transitional care management can be a product that we provide to a specific payer or risk organization, coupled with chronic care management for a post-acute care bundled program. CMS allows physicians (of any specialty) to furnish TCM services. CMS also allows legally authorized and qualified non-physician practitioners (NPPs), clinical nurse specialists (CNSs), nurse practitioners (NPs), and physician assistants (PAs) — to perform TCM.
For more information on CCM, please visit CMS.gov.
An estimated 117 million adults have one or more chronic health conditions, and one in four adults have two or more chronic health conditions. Through the Connected Care Campaign, the CMS Office of Minority Health and the Federal Office of Rural Health Policy at the Health Resources & Services Administration is raising awareness of the benefits of Chronic Care Management (CCM) for patients with multiple chronic conditions and provide health care professionals with resources to implement CCM. CCMS-ACO’s technology not only supports CCM, but facilitates it in a manner that both optimizes patient care, but also optimizes the processes related to CCM.
For more information on CCM, please visit CMS.gov.
Primary Care First Primary care is central to a high-functioning health care system and thus, there is an urgent need to preserve and strengthen primary care as well as a need for support of complex, chronic, and serious illness care services for Medicare beneficiaries. PCF addresses these needs by creating a seamless continuum of care and as a result, accommodating a continuum of interested providers at multiple stages of readiness to assume accountability for patient outcomes.
Primary Care First CMS 2020 Initiative: We Have Selected to Be a High Need Populations Payment Model Option
Remote Patient Monitoring makes it easy to track your patients and deliver interventions quickly and effectively. Our package includes the capabilities to speak to patients live or if because of some escalation, the doctors can speak and see patients through our Telemedicine tablets. RPM is customizable to individual patient needs, delivers better outcomes at lower costs, and will improve key metrics. As of January 1, 2019, CMS has made remote care a separate, billable service.
Remote Patient Monitoring and Telemedicine
The demand for Commerical ACOs undeniably exists and is clear. The services we are providing are similar to a sister program known as Medicare Shared Savings Program (MSSP). Innovating well-documented initiatives that have proven to provide “best practice” standards increases quality and participation among the continuum of care providers through interoperable collection of data. Well-documented coordination of care reduces costs in healthcare by providing a more comprehensive health care record and consequently, a superior basis for the optimal care plan.
Commercial Accountable Care Organization
We have established a creative relationship with Kindred Gentiva, who is the country’s leader in home care services. Their decades of experience in the field, as well as their clinical and infrastructure supports have enhanced the services we offer.For more information on Kindred Gentiva, please visit Kindred at Home.
Strategic Alliance with Kindred Gentiva
Post-Acute-Care Provider (PAC) Primary Care Virtual Practice