Chronic Care Management and Monitoring for Your Most Complex Patients
Circle Home Telehealth Services offers a program of telehealth and remote care management services focused on helping your high-risk Medicare patients who are living at home.
We enable you to keep a close eye on your patients between visits so they may better manage their care to minimize or prevent breakdowns in their health and avoid emergency room visits, hospitalizations, or other institutional care.
Physicians and Nurse Practitioners
Registered Nurses
Social Workers
Expanding Your Circle of Care
You and your patients will have access to a dedicated, multi-disciplinary care team.
Our comprehensive, frequent remote visits and monitoring of patients provides you with clinical insights between office visits. We will keep you informed of changes and alert you with concerns.
We Care for the Patients You Worry About the Most and Who Also Have
Traditional Medicare & Medicare Advantage
Multiple Unstable Chronic Conditions
Polypharmacy
Getting Your Patients Enrolled is Easy
Select complex patients you worry about
Eligible patients are those complex patients with two or more chronic conditions that are likely to destabilize if their treatment is not carefully managed.
Share Information with your patient
Tell your patients about the services Circle Home offers and, with the patient’s permission, let us know your patient is interested.
Circle Home Telehealth Services (CHTS) Commitments To You as a Referring Provider
- We will monitor your highest risk “most complex and likely to breakdown” patients and keep you informed – especially when there is a change or decline in their health or ability to self-manage their treatments.
- After you make a referral, we will engage your patients, inform them of what they need to know about care coordination services, gain their voluntary consent to receive these services and never pressure your patients to enter a care plan.
- Our NP and RN care coordinators will create a comprehensive care plan for and with your patients that is specifically designed to better enable their overall treatment to be fulfilled.
- We will not change your treatment plan for your patients without first consulting with you and working collaboratively together to develop a path forward for your patients.
- We will reinforce the importance of your patients’ relationship with you and other treating providers in coordinating their care.
- We will discover the every-day challenges and obstacles your patients have in self-managing their care at home and in complying with their treatments – and then, help minimize or remove these challenges.
- We will monitor and improve your patients’ ability to actively participate in their health care through a proven patient activation measurement feedback process and, in so doing, attain higher patient engagement and satisfaction levels with their care. We will measure this satisfaction periodically and report the results to you.
- We will help your patients better understand their medications, the conditions these medications treat, how/when they are to be taken and what their side effects are so they can better comply with their medication regime.
- We will monitor biometric trends/patterns for your patients, document this data in the patients’ CHTS electronic health record and share the data monthly (or as frequently as requested/needed) with you and other treating providers.
- We will fairly compensate you for the services you have agreed to provide in supporting CHTS’ efforts in coordination and monitoring of your patients as listed below.
Your Commitments to CHTS as a Referring Provider
- You agree to actively identify potentially eligible patients in your practice, inform them of the benefits of care coordination and tell them why you recommend their participation in CHTS care coordination services and make a referral if they agree.
- You agree to participate in bi-directional patient record/data sharing via secure electronic interface to ensure that both you and CHTS have access to timely, relevant patient information to support efficient and effective care coordination.
- You agree to promptly review and provide feedback on care plans or other information regarding your patients’ progress or decline in health status when sent to you by CHTS and cooperate with CHTS in responding to requests from payers or regulatory bodies regarding claims or other aspects of care coordination for your patients.
- You agree to collaborate with CHTS as needed in collecting, compiling, and monitoring and interpreting biometric readings on your patients being coordinated by CHTS.
- You agree to comply with CHTS’ policies and procedures and reasonable requests for assistance when this is needed by CHTS in coordinating the care of your patients.
Circle Home Telehealth Services (CHTS) Commitments To You as a Referring Physician
- We will monitor your highest risk “most complex and likely to breakdown” patients and keep you informed – especially when there is a change or decline in their health or ability to self-manage their treatments.
- After you make a referral, we will engage your patients, inform them of what they need to know about care coordination services, gain their voluntary consent to receive these services and never pressure your patients to enter a care plan.
- Our NP and RN care coordinators will create a comprehensive care plan for and with your patients that is specifically designed to better enable their overall treatment to be fulfilled.
- We will not change your treatment plan for your patients without first consulting with you and working collaboratively together to develop a path forward for your patients.
- We will reinforce the importance of your patients’ relationship with you and other treating providers in coordinating their care.
- We will discover the every-day challenges and obstacles your patients have in self-managing their care at home and in complying with their treatments – and then, help minimize or remove these challenges.
- We will monitor and improve your patients’ ability to actively participate in their health care through a proven patient activation measurement feedback process and, in so doing, attain higher patient engagement and satisfaction levels with their care. We will measure this satisfaction periodically and report the results to you.
- We will help your patients better understand their medications, the conditions these medications treat, how/when they are to be taken and what their side effects are so they can better comply with their medication regime.
- We will monitor biometric trends/patterns for your patients, document this data in the patients’ CHTS electronic health record and share the data monthly (or as frequently as requested/needed) with you and other treating providers.
- We will fairly compensate you for the services you have agreed to provide in supporting CHTS’ efforts in coordination and monitoring of your patients as listed below.
Your Commitments to CHTS
- You agree to actively identify potentially eligible patients in your practice, inform them of the benefits of care coordination and tell them why you recommend their participation in CHTS care coordination services and make a referral if they agree.
- You agree to participate in bi-directional patient record/data sharing via secure electronic interface to ensure that both you and CHTS have access to timely, relevant patient information to support efficient and effective care coordination.
- You agree to promptly review and provide feedback on care plans or other information regarding your patients’ progress or decline in health status when sent to you by CHTS and cooperate with CHTS in responding to requests from payers or regulatory bodies regarding claims or other aspects of care coordination for your patients.
- You agree to collaborate with CHTS as needed in collecting, compiling, and monitoring and interpreting biometric readings on your patients being coordinated by CHTS.
- You agree to comply with CHTS’ policies and procedures and reasonable requests for assistance when this is needed by CHTS in coordinating the care of your patients.