Chronic Care Management Services with CareSync

Regional Family Medicine now offering Chronic Care Management services for Medicare Advantage patients through partnership with CareSync

Regional Family Medicine is proud to announce our partnership with CareSync, the industry-leading provider of care coordination services.  This partnership was developed in order to provide Chronic Care Management (CCM) services to our Medicare Advantage patients.  CCM services are a benefit offered by Medicare to allow for a higher level of contact with your provider for patients who have two or more chronic conditions that are expected to last longer than 12 months and contribute significantly to your risk for complications. 

Medicare has recognized that patients with chronic conditions such as diabetes, high blood pressure, heart disease, as well as many others, are at higher risk for complications and general decline.  We are currently enrolling Medicare Advantage patients in this program.  Depending on your individual policy, you may have a small copay or coinsurance.  The benefit provides for contact from our CareSync clinical partners for at least 20 minutes monthly in order to better coordinate the many moving parts of the healthcare picture for our patients with chronic disease.

What should patients expect from CCM services with CareSync?

  1. CareSync will have access to your medical records at Regional Family MedicineWhen you sign up for CCM services, one of the permissions you will grant is for your Care Sync Health Assistant to directly access your electronic medical records at Regional Family Medicine.  One of the major benefits of CCM services is all members of your care team having access to the same information.  This will allow your health assistant to help coordinate the various aspects and moving parts of your healthcare team.  CareSync is held to the same privacy standards as all your medical providers under regulations such as HIPPA.  The privacy and security of your health information will be given the highest priority.
  2. 24/7 Access to Clinical Staff.  CareSync Health Assistants are available 24 hours per day, 7 days per week, via phone, email, and in-app messaging.
  3. Continuity of Care.  CareSync's Health Assistants help patients schedule appointments with the designated provider and ensure comprehensive health information is consistently shared with the entire care team.
  4. Care Management.  When the provider creates an Assessment and Plan, Health Assistants will obtain the information to create tasks, medication & measurement reminders, and more important information in a format that the patient and care team can easily understand and engage.  The information is completed and updated to the provider, who is able to adjust the care plan according to documented results.
  5. Care Plan. A comprehensive Care Plan is created with the required elements: Problem list, expected outcome and prognosis, measurable treatment goals, symptom management, planned interventions, medication management, community/social services ordered, coordination of other agency and specialist services, etc.  To accomplish this, CareSync's Health Specialists retrieve this information from the patient, the patient's care team, and the Assessment & Plan gathered from each of the patient's active providers.  The comprehensive health information is always available to every member of the patient's care team, as each provider and family member is offered a free CareSync account.
  6. Care Transitions.  CareSync's Health Assistants refer patients to other clinicians in a timely manner, retrieve the records from each visit associated with the trigger event, update the patient's information, and share it with every member of the care team.
  7. Coordination with Other Providers. Every visit with the primary care team as well as home- and community-based providers is recorded, the Care Plan is updated, and every Provider has access to the documentation via the free CareSync application and pushed updates. If the Plan includes a referral to another provider or service, all the providers can view the activity associated with it.
  8. Patient and Caregiver Access (Asynchronous).  CareSync was created with the idea that caregivers are often the best source of information about the patient.  The revolutionary ability for families to interact with the information, share information before the visits, listen to a recording of the doctor's instructions, and respond to notifications when a reminder is missed ensures that CareSync caregivers have the best possible opportunity to facilitate patient care and give the provider a new level of useful data.  Caregivers get email and device notifications and activity summaries, and are encouraged to interact with the patient and Health Assistants via in-app comments and notes.
  9. Does CareSync do anything beyond Medicare's requirements?
    We're glad you asked!  These are just a few:
  • Timeline.  CareSync's trademarked Health Timeline is an important part of the patient's history and the care team's understanding of what has been done lately.  The most recent 30 days of Timeline activity is included with the monthly update to all current providers. 
  • Caregiver Accounts.  The patient's family members and other caregivers not only have access to the patient's information, they are encouraged to create their own accounts so they are truly engaged with the application.  
  • Medication & Measurement Reminders. Medication & measurement instructions are part of every Care Plan, but CareSync turns it into an engaging opportunity to generate useful data and complete the communication loop with the providers.
  • Visit Planning Tools.  Many patients forget what they were going the ask the doctor at a visit, and even more forget what they were told.  Patients and caregivers are encouraged to plan the visit by adding notes and tasks that are transmitted to the provider before the visit. A voice recorder built into the app allows the doctor's explanations and instructions to be saved to the visit and are immediately available to the entire care team.
  • Medical Records.  In order to review the patient's Assessments and Plans, the Health Assistants get actual medical records from each of the current providers, and records for any visit while the patient is a CCM plan member.  The records include SOAP notes, images, lab results, and anything associated with the visit.

If you would like more information or if you are interested in signing up for CCM services, please contact your care team or call (870) 425-6971.

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