Blueprint

YOUR STEP-BY-STEP

ROADMAP TO SUCCESSFULL

PHYSICIAN-PATIENT ENGAGEMENT

Through Lifestyle Medicine Care Coordination

Denise Campbell, MSPH, CHES

POPULATION CARE COORDINATION

1 Lifestyle Medicine

Lifestyle Medicine Care Coordination is the evidence-based practice of partnering with lifestyle practitioners in assisting individuals and their families to adopt and sustain behaviors that can improve their health and quality of life.

Exercise Nutrition Stress

Resilency Adequate

Sleep Avoidance of Tobacco

Moderation of Alcohol

Modifiable Components of Lifestyle Medicine

Scope of Practice

Health Problem

Determine Need

Partner with Integrative Health

Practitioners

•Certified Personal Trainers

•Certified Nutritionist

•Registered Dietitions

•Certified Health/Wellness Coaches

•Naturopathic Doctor

•Osteopathic Doctor

•Acupuncturist

Healthy At-Risk Pre-Chronic Chronic Disease

Stratified Population Engagement

Lifestyle-Related Risk – Risk for Progression – Risks for Complications – Risk to Quality of Life

Health Problem + Scope of Practice Diabetes = Massage for Edema & Lymphedema Diabetes = Glucose Control Exercises Diabetes = Diabetic Educator

Find Integrative Health Partners

Lifestyle Medicine Practitioners

All searchable in one cohesive platform

already credentialed & qualified to work

with your patients.

Chiropractor

Massage Therapist

Stress Management Experts

Financial Advisors

Faith-Based Organizations

Community-Based Organizations

Other Holistic/Integrative Modalities

The Institute of Lifestyle Medicine, Harvard Medical School

Partners

2

Referrals

POPULATION CARE COORDINATION

Direct Search By: Integrative Practitioner

Specialty

Geographical Area HEDIS Measures

Call In Concierge Services

Referral & Centralized Real-Time Scheduling

Identifies and focuses

on HEDIS gaps in care.

Prescribe Lifestyle

Medicine

Lifestyle Medicine

Information Exchange

Population Care

Coordination Services

Supports Achieving

Meaningful Use

Ability to Link with

Personal EHR

Never lose track of your

patients and have real-

time access to case

files.

All modalities are matched

with HEDIS measures to

ensure maximum revenue.

Our specialized care

coordinators can help

reduce ED visits and

readmission rates.

Our bi-directional

communication platform

allows patients and

families to fully engage

Outfitted with a backend

API to ensure full

integration of care plans

with a patient’s EHR

Patient Enrollment Physician Referral

Self-Referral Must have PCP involvement to continue

Scheduling/Appointments

Charting

Communication

Workflow Documentation Collaborative care tasks & workflow

Bi-directional communication with

entire care team, patients and their

families.

Centralized, real-time data and

charting that is integrated into one

electronic health record.

Billing and contract management

Referral Management

Integrative Practitioner In-Take Coordination

3 Collaborative Care

Patient Engagement

Treatment Plan

Treatment Tracking

Evidence Based

Behavior Change Strategies

Self-Management

SStrategies

Measure Outcomes

Report Outcomes

POPULATION CARE COORDINATION

As recommended by the attending

physician.

Bi-directional communication platform

that encourages patient initiation for

Meaningful Use measures.

PCP Dashboard IP Dashboard

Patient/Family

Dashboard

Patient

Primary Care Providers

Paper /Other

Offline Referral 3-Way Communication Meaningful Use

Integrative Practitioner

PCP Dashboard Components

“Brief Case Manager” SEARCH FOR IP BY SPECIALTY,

GEOGRAPHICALLY, OR BY HEDIS MEASURES

ACCESS TO ONLY THEIR PATIENT CASE FILES,

EMAIL AND COMMUNICATION COMPONENT.

REFERRAL & CENTRALIZED REAL-TIME

SCHEDULING

CASE FILES – INDIVIDUAL/FAMILIES/GROUPS

CUSTOM DEMOGRAPHICS

HEDIS MEASURES

CAPTURE ALL CORRESPONDENCE, CONTRACTS

AND APPOINTMENTS WITH CONSUMERS, PCP’S,

FAMILY MEMBERS, COLLEAGUES AND THIRD

PARTY PAYERS

INTAKE/REGISTRATION PROCESS AND CLIENT

ASSIGNMENT PROCESSES

CUSTOMIZE FORMS (IN-TAKE, TREATMENT

PLANS, SHIFT NOTES, SURVEYS, LETTERS, ETC.)

OUTCOME ASSESSMENTS (EACH IP AS WELL AS

AGGREGATE DATA FOR THE OVER-ALL

NETWORK)

SECURE EMAIL, ALERTS, NOTIFICATIONS,

WORKFLOW AND COLLABORATION TOOLS

WORKER PROFILES WITH SCHEDULING

AVAILABILITY

DIGITAL SIGNATURE CAPTURE

ACCOUNTS RECEIVABLE WITH FLEXIBLE SELF-

PAY AND THIRD PARTY BILLING INCLUDING

AUTHORIZATION TRACKING AND

INSURANCE/EAP BILLING (INTEGRATED 837 P

EDI CLAIM AND CMS – 1500 GENERATION)

INCLUDING CREDIT CARD PROCESSING.

iHealth Partners

Network Flow Chart

Make a referral Focuses on HEDIS gaps in service

Real-time access to patient lifestyle medicine cases