Chronic Disease and Behavioral Health Coach Training

ACO_12_Chronic Disease and Behavioral Health 2017-09-13T20:09:48+00:00

For Care Coordinators, Practice Champions, IT Staff

Everything you need to know to help chronically ill patients get the care they need, build market share and begin billing Medicare with the new Chronic Care Management and Transitions of Care Management codes.

PROGRAM DESCRIPTION

The essential element for value-based payment success is the coordination of care for patients with multiple chronic diseases. Special attention will be paid to managing the chronically ill, promoting evidence-based practices and helping patients learn self-management of their disease. Patients with two or more chronic conditions will be encouraged to participate in your Care Coordination program, resulting in better outcomes, lower per capita costs and better alignment with the 20% of your patients that comprise 80% of healthcare spending in your community.

Generally led by a nurse in your practice or community, the Care Coordination program will use both local and virtual care teams of pharmacists, mental health professionals, advice nurses, nutritionists and community resources to support this fragile population. They will take the burden off of the physicians in the clinics and the emergency room by providing the support needed to manage their disease and avoid unnecessary hospitalizations and readmissions. Regular physician visits will be supported by clear patient goals to maximize compliance and adherence to the care plan. Referrals will be tracked and accompanied by patient data and care coordination support, ensuring a closed loop of information and the avoidance of wasteful, duplicate procedures.

The care coordinator will use the Lightbeam Health Care Management module to develop care plans, track patients’ progress and document their work for Chronic Care Management billing. Lightbeam predictive analytics will be used to create patient registries to identify patients who can benefit from Care Coordination.

Our evidence-based Nurse Advice Hotline has 24/7 access to the electronic care plan through Lightbeam, enabling you to successfully bill Medicare an average of $40 for each patient your care coordinator provides care management support for a minimum of 20 minutes per calendar month. Our care coordinator mentors, cohort calls, training, workshops and certification are all designed to develop this important skill within your practice.

TOOLS PROVIDED

Nurse Advice Hotline Questionnaire
Care Coordinator Questionnaire
Quarterly Quality Improvement Workshops
Lightbeam Health Care Management Module
Sample Care Coordinator Care Plans
24-Hour Nurse Advice Hotline with access to your Electronic Care Plans
Iowa Chronic Care Consortium Online Training Program
In-Person Health Coach Certification
Chronic Care Management Billing and Coding Workflows and Assistance
Individual Care Coordinator Mentoring
Care Coordinator Cohort Calls

WHERE TO LEARN

Quality Improvement Workshops
Iowa Chronic Care Consortium Online Training Program
Webinars On Demand
Care Coordinator Cohort Calls

WEBINAR AND WORKSHOP TOPICS

Transitions of Care Management / Chronic Care Management Overview
Establishing Your Nurse Advice Hotline
Chronic Care Management Billing for Medicare
Lightbeam Health Care Management Module
Iowa Chronic Care Consortium Training Program

NOTE: THE NURSE ADVICE HOTLINE CAN BE EXPANDED FOR PATIENTS BEYOND MEDICARE FOR A FEE OF $0.25 PER PATIENT PER MONTH.