Wiki Interactive Contact for Transitional Care Management Services

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Appreciate any thoughts or information anyone can provide...

Does anyone have a reference on whether or not the interactive contact can be anything other than telephone, email or face to face can a different technology be used?

Our primary care uses RNs on our team primarily to do the 2 day interactive outreach that is required for the TCM services. Just this spring we launched use of a tool called GetWell (loophttps://www.getwellnetwork.com/getwell-loop/) for our transitioning patients that applies a technology that allows patients to check in, complete education, write comments or questions in, and we have it operationalized now where if they do flag with an “alert” or have a comment that we have an MA or RN on our team reach out to the patient.

If we decide to expand our GetWell loop technology to other discharges (beyond the contracted lives that we cover with care coordination) if that electronic check in suffices for TCM billing? I’m having trouble finding a Medicare endorsed description of what counts for “electronic check in” beyond the very basic descriptions in the FAQs. Would use of the GetWell loop be sufficient?

The GetWell loop is a digital care management software tool that offers interactive communication between the transitioning patient to the RN/auxiliary staff.

Currently within 2 business days the GWL electronic technology would assess the patient in the following ways (for both high risk and low/moderate risk):

- Within 1-2 days of discharge (if they activate their account):

o Understanding of diagnosis (if no or unsure- contributes to yellow alert)

o Ensuring patient education (if wants more details- contributes to yellow alert)

o Reminder to fill prescriptions

o Assessment if problem has worsened (if worsened- red alert)

o Assessment of pain (if yes, yellow alert)

o Education on symptoms to monitor after discharge

o Education on managing medications (via video)

o Provides a medication log as a resource tool
 
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