Driving CCM as
a collaborative service
Transforming Care Delivery
Through Remote Telehealth
Orb Health is the only intelligent, collaborative care telehealth solution that delivers improved patient outcomes, increased health system revenue, and decreased cost resulting in maximized value-based profitability.
Step 1 - Automated Patient Eligibility Discovery
Orb Health’s HIPAA compliant, secure, and encrypted infrastructure synchronizes with the health systems EMR system. Chronic Care Management eligible patients are automatically discovered and organized for the Orb Health enrollment team.
Step 2 - Patient Enrollment Campaign
Orb Health’s enrollment team executes a systematic outreach campaign through multiple methods of communications, resulting in a phone conversation.
A CMS code-compliant script that explains all of the benefits, requirements, and verbal consent questions needed for the patient to compliantly agree to the service is followed and each response is documented for auditing purposes.
Step 3 - Enrollment Compliance Check
As the patients confirm their acceptance into your health system’s CCM program, their responses and interactions are checked by the Orb Health compliance team before final enrollment is processed. This is to ensure all actions were taken compliantly and the record is audit-ready.
Step 4 - Care Delivery
Once a patient is enrolled, a 3-nurse care pod is assigned, a personalized care plan is created and recorded in the EMR, and the first appointment is scheduled.
Subsequently, each the month, a nurse will proactively reach out to meet the requirement for 20 minutes of non-face-to-face time between office visits. They will coordinate a wide variety of care services. The nurse pod is also available 24/7 to speak with patients.
Every interaction is noted and synchronized with the EMR system so the Primary Care Physician and team is always up-to-date on the patients status.
The infrastructure also provides predictive algorithms that warn the nurse pod about any possible patient issue that could be forming. The nurse can proactively reach out to the patient to head off an incident.
If a crisis does occurs, the nurse pod will contact the Doctor to coordinate proper care for the patient.
Step 5 - Interaction Compliance Check
Interactions and documentation are routinely checked by Orb Health’s dedicated compliance department to ensure that all information meets requirements before it is synchronized back to the EMR. This ensures that your health system’s CCM program is always audit-ready.
Step 6 - Measure Patient Outcomes
Combined with the EMR system, the Orb Health infrastructure provides large amounts of valuable data and meta-data on patients metrics. The resulting analytics will raise all sorts of important observations that help streamline care, improve patient outcomes, measure ROI metrics, and set your health system up for Value-Based Care success and MACRA/MIPS compliance.
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