Care Coordination

Q. What should my patients expect when receiving care coordination from HealthWatch?

A. Patients can expect to receive care coordination one of two ways:

  1. Monthly calls - we strive to coordinate a mutual time to speak with the patients. At that time, our staff contacts each patient on the phone and spends 20 minutes every month discussing their care plan and progress toward the patient’s individual healthcare goals.
  2. Mailed care coordination – after two attempts to call the patient and leave voicemails, if the patient does not call back their medical care coordinator within 2-3 business days, they will receive care coordination through the mail. The patient receives patient education (differs each month), a paper medical exam to complete, a medication list to complete and a return envelope and stamp to return their care coordination items. This is all documented in the clinical note within the patient’s chart.

Q. How is the care coordination documented?

A. Each visit is documented in a patient specific care plan, whether the patient received care coordination over the phone or through the mail. This care plan becomes a locked medical note, which lives in their HealthWatch chart.

Q. What does my patients care plan consist of?

A. The medical care coordination team will conduct care coordination with the patient each month, which includes, but is not limited to, the following:

  1. Reconciling of medications and medication education
  2. Health questionnaire – we utilize a very detailed condition management care plan to review the patients general health and chronic condition progression, any additional chief complains from the patient during the visit are also documented (urology, nephrology, cardiology, mental health, general health, neurology, COVID-19). We are happy to share a copy of this care plan with the practice at any time
  3. Care Plan Review
  4. Patient Education – unique to each visit

Q. What else do you do to help coordinate care for my patients outside of their standard monthly visit?

A. We strive to help patients with as much as possible, a few examples include:

  1. Medication refills to the practice and the pharmacy
  2. Appointment scheduling and management to other specialists, PCP, etc.
  3. DME Supply coordination (Blood pressure monitors, walkers, CPAP machines, etc.)
  4. Call on the patient’s behalf to receive their imaging and lab results
  5. Schedule appointments with the practice for follow-up
    1. If a patient notes they went to the ER/were hospitalized, we call the practice(s) to schedule a follow-up appointment
  6. Coordination transportation for the patient as needed

Q. Do you have testimonials from patients on their experience with HealthWatch CCM?

A. Yes! We are in the process of building a landing page on our HealthWatch website where you can find great feedback from our CCM patients. We also share patient testimonials regularly with our customers as we receive them from our patients.