On-site prospective health assessments and HEDIS gap closure
Advanced technology + highly trained clinicians = superior results
Prospective Health Assessments
Tailored, AWV-compliant, comprehensive health assessments delivered in the home or in a more traditional setting such as a doctor’s office or community center.
HEDIS Gap Closure
Improved HEDIS and other Stars quality measures through a wide selection of point-of-care services, including blood analyses, urine analysis, cancer screening, bone density testing, and seasonal vaccinations.
Personalized Prevention Plans
Leveraging the data collected during the on-site health assessment, we’re able to drive tailored recommendations to multiple stakeholders, including the primary care team, revenue management, quality teams, and the member.
Prospective On-Site Health Assessments
Our on-site health assessments are performed by highly trained Nurse Practitioner and Documentation Specialist teams in the home or in a clinic or similar location. Our unique team model, when combined with our purpose-built mobile technology, allows for a more dynamic and focused interaction leading to a higher quality visit. Each visit is approximately 45-60 minutes, depending on the complexity of the member being assessed and the number of additional Stars tests performed. Our comprehensive health assessment consists of:
- Health risk factors survey, including comprehensive needs and functions assessments and substance abuse screening
- Past medical history, including resolved diagnoses, surgical history, preventive screening history, and family history
- Current and past medication reconciliation
- Cognitive impairment and depression screening
- Current diagnoses capture and related clinical assessment
- Complete review of systems and physical examination, including a gait assessment, hearing test and walking speed test
- Home and environmental assessment
- Personalized prevention plan
- Tailored one-on-one health education
Tailored to achieve the prospective risk adjustment goals of our clients.
25 Stars Gaps
Directly meets or identifies gaps for 25 different Part C Stars measures.
Our assessment meets the CMS guidelines for the Medicare FFS Annual Wellness Visit.
Our assessment design and 99% quality rating means less exposure to RADV audits.
HEDIS and Stars Gaps Closed at the Point-of-Care
Our health assessments reveal the Stars or other quality gaps and our clinicians close them at the point-of-care using a broad range of labs and tests. The results are added to our health assessment prior to coding and are highlighted within our follow-up recommendations. We triage the results and immediately notify the member and the primary care team of abnormal results. Some of our more common labs and tests include:
HbA1C & LDL
A finger stick blood test collected at the point-of-care and mailed to our certified lab partner. Tests for blood sugar and cholesterol levels.
FOBT Colorectal Screening
Our clinicians provide education on how to properly self-administer the leave behind, pre-paid mail-in fecal sample collection kit used to screen for colorectal cancer.
Medication reconc iliation is a great step towards better medication adherence; however sometimes a more hands-on approach is needed to ensure long-term results. We offer a range of personalized ‘high- and low-touch’ programs to help improve medication adherence.
A urinalysis, collected at the point-of-care, tests the kidney function in diabetic patients. The urine sample is collected and mailed to our certified lab partner for analysis.
Bone Density Exam
Our achilles bone ultrasonometer exam gauges the risk of bone fractures related to osteoporosis. Results are produced instantly and provided to the patient at the point-of-care.
Influenza and pneumonia are major causes of avoidable hospitalizations. We screen members and seasonally administer vaccines to help them stay healthy and out of the hospital.
Actionable, Tailored Data
A comprehensive set of data is only as good as the action plan created with it. That’s why we always document everything 100% electronically and have built a flexible software platform that allows us to automatically tailor the outputs to the needs of the intended stakeholder.
- Primary Care Team
- Revenue Management
- Quality (Stars) Team
- The Member: Personalized Preventive Care Plan
Gap closure and continuity of care is a primary goal of every service we complete. We believe that engaging the primary care team and providing them with valuable, meaningful information is crucial to improving health. We deliver tailored personalized preventive care plans to the primary care team of each member we see. Our personalized preventive care plans include recommendations that:
- Are actionable, evidence based, and linked to quality measures
- Are tailored to each member based on the assessment
- Identify gaps in care
- Are designed by clinicians for optimal communication
We collect data during the assessment in a format that is optimized for coding, making it easy for us to provide our clients with usable data in a variety of plan-centric electronic formats. Our risk-adjustment trained medical coders work thoroughly and quickly so that our clients can, in turn, submit HCC data to CMS for payment determination.
- 95% guaranteed reliability of coding (with 25% over-read)
- Certified clinical coders for accurate, in-depth review
- Thorough validation of all diagnosis codes in chart and codes hitting HCCs
- Fully captured RxHCC Codes for Part D Risk Score calculation
We recognize that HEDIS and other quality measures are just as important as risk adjustment. Our certified medical coding team also documents quality-related data, which our technology platform then formats into an output according to the needs of the plan for submission to the regulating authority.
- Documentation of quality gaps closed during our health assessment (e.g. BMI, fall risk, pain screening) or through point-of-care preventive services (e.g. HbA1C, FOBT colorectal, microalbumin)
- Quality measures previously conducted by other care teams (to ensure information is tracked back to the plan)
- Opportunities for further gap closure through follow-up care
- Personalized list of recommended preventive screenings and tests
- Tailored one-on-one health education
- Contact information for local social services and related assistance programs
- Coordination of care plans and connecting members with the information and help they need to get and stay healthy