Physicians can now get reimbursed for the coordination effort that is involved in managing a patient following a hospital discharge. ACT.md's unique TCM-specific Health ACT Sets facilitate a structured, standardized, and proven process for optimal care coordination to reduce hospital re-admissions and support TCM billing. The ACT Sets are structured in a way for providers to assess complexity, complete care actions required by CMS, and follow specific time sensitive requirements for care delivery and billing. ACT.md takes the complexity out of the TCM Billing process and pays for itself within months.
Between-visit care is critical to the health outcomes of a patient with multiple chronic conditions and starting in 2015, CMS will reimburse providers for care coordination services. ACT.md is the secure communication platform for sharing and executing upon the care plan.
ACT.md provides true patient-centered, multi-author care planning in a real-time and action-driven framework. ACT.md facilitates obtaining the required informed patient consent, secures an audit trial for care coordination activities, provides a reliable process for managing care transitions, and gives increased access for patients to their care team through an easy mechanism for structured communication. With ACT.md providers can track, understand, and report on the total care coordination work done by all members of their care team as well as improve coordination within your organization and with partners in the community involved in the chronic care management of your patients.
ACT.md provides a common communication platform – nursing homes, skilled nursing centers, long-term care facilities, & rehabilitation facilities can now be on the same page as hospitals, other treating providers, and resources in the community. ACT.md promotes a predictable, structured hand-off promoting safety and reducing risk and duplication of services. Providers in the acute and post-acute settings can immediately zero in on critical activities associated with a patient transitioning instead of having to navigate paperwork and unfamiliar terminology.
ACT.md brings together best practices, such as Boston University Medical Center's "Re-Engineered Discharge", and automates the discharge coordination process. With the click of a button, 12 components proven to reduce re-hospitalizations and produce high levels patient satisfaction are put into action. The tasks are assigned to specific responsible roles with a due date defined. In ACT.md, the discharge advocate, nursing staff, primary care team, and outside service providers (PT, OT, VNA) are all brought together in a common space. Everyone knows the discharge plan and their specific responsibility and are accountable held to ensure a smooth transition from acute care to community care.
ACT.md facilitates a closed loop referral process. The assignment of a referral Health ACT Set informs the PCP, Specialist, Referral Coordinator, and Patient of the tasks associated with the referral such as obtaining insurance information, appointment reminder, forwarding the consult note, and confirming the appointment occurred. The network is mapped and ACT.md makes it easy to communicate with in-network specialists even in a very heterogeneous IT environment. Now the responsibility for a specialty appointment does not fall solely on the patient and Network's have visibility into referral patterns.
Unique to ACT.md, patients, their families, and caregivers are knowledgeable and accountable members of the care team. Think of ACT.md like a healthcare GPS for patients and families; ACT.md significantly reduces the complexity of navigating the healthcare system. Patients know who is involved in their care and can track all associated activities in this personalized experience.
ACT.md promotes patient centeredness with activities and teams mapped around a patient and provides the ability for collaborative care planning and shared decision-making.
With highly personalized and digitalized education, patients and caregivers can be more effective in self-managing everything that needs to take place in-between visits. Patients and caregivers can keep notes related to their care in ACT.md and assign tasks to each other. Patients and families can communicate with the members of their care teams by asking questions related to specific activities and through discussion groups.
ACT.md was built to fit into the reality of people's lives and to meet them where they are. Patients can be engaged through a web-based application that has a similar look and feel to social networking sites like LinkedIn, Facebook, and Twitter, with easy to understand language or by interacting with ACT.md resources that call them directly to provide assistance in getting activities associated with the care plan completed.
Organizations have real-time visibility into how patients and caregivers are engaging therefore can understand how to influence optimal outcomes.
Many organizations have sophisticated tools to aggregate and analyze data to identify high-risk patients and gaps in care but many are retrospective and provide no method to act upon that data and see necessary tasks through to execution. ACT.md is productivity, workflow, and communication tool to make the job of a Care Manager or Coordinator easier. Phone, fax, spreadsheets, sticky notes and email are replaced.
With ACT.md, Care Managers and Care Coordinators can connect with patients, providers, and community resources in one place, but unlike a simple communication tool, ACT.md drives action through the assignment of work across the team. The ACT.md Dashboard allows Care Managers to know where they need to focus and the powerful filter, tagging, and search capabilities simplify panel management. With the click of a button a task (such as a reminder to get a colonoscopy) can be assigned to all patients in a panel or a category specific subset, increasing reach and therefore increasing capacity. Managers have real-time insights into the completion of critical tasks and can monitor care manager workload.
Have you ever wanted to start using a project management tool you've used in other facets of your life but as a clinician realized you couldn't due to the lack of HIPAA compliant security? With ACT.md you now have a safe, secure way to manage projects in healthcare. Tasks are assigned with due dates, documents can be stored and shared, project teams have a virtual space to have discussions, and there is visibility into progress or risks.
Ranging from organizing clinical conferences, to quality improvement projects and hitting all your Maintenance of Certification milestones, pursuing NCQA PCMH accreditation, or becoming a Medicare Shared Savings ACO, ACT.md makes it easy to execute on goals and manage required program components across your teams, and across organizations, securely and simply.