Population Management Redesigned
Continuous Patient Tracking
Patient vitals are transmitted continuously into the OverSightMD patient population management dashboard and monitored by TeleCare wellness nurses. Patients recovering at home will be contacted and asked specific questions based on alerts generated by the data that they are sharing through the device or through the multiple options available for self-reporting symptoms or health concerns. These patient engagements are utilized by the TeleCare nurse to provide best practice level advice and expedite all care issues to the appropriate care provider for the patient.
Nurse Monitoring Vitals & Symptoms
Wellness nurses monitor all patient data including symptoms, vital signs, and other changes in condition. They will engage patients to receive additional information and incorporate it into actionable updates for care providers. Providers can access in real-time all continuous patient updates from TeleCare nurses in the dashboard. Clinical teams acting on alerts from TeleCare nurses reduce readmission by delivering timely care to patients at risk. The TeleCare system assists providers to prioritize responses. Health analytics are available on an individual basis and whole populations to share with referral sources to improve case conference meetings and data sharing capabilities.
Alert Based Interventions
cRPM is the most proactive care model available for patients recovering at home or in skilled nursing. Tracking data immediately stratifies risk among patient populations. Changes in vitals and symptoms are the leading cause of alerts from the TeleCare team to providers; however, there are many other problems that cause preventable readmissions. These include unanswered care requests, delays in care, questions with care plans, DME issues, concerns about a family caregiver, financial issues, medication questions, mental health issues, PCP coordination, transportation coordination, and other social determinants. Care providers can improve their workforce’s care utilization and stay laser-focused on the highest risk patients while TeleCare nurse triage steps in and addresses social determinants of health and expedites the most important cases.
Analytics for Providers
The OverSightMD platform delivers real-time analytics for care providers for their entire population. Providers have the ability to run reports on alerts by the individual patient, by facility or region, and by their entire population. Patient reports are easily shareable with referral sources and primary care physicians and other specialists so everyone is on the same page regarding recent changes in a patient’s health. With on-demand analytics about current patient’s care at home, providers now have a proactive readmission defense strategy.