Aftercare Assurance™

Our oversight and continuum of care service is designed to align skilled nursing facilities and home health agencies with the requirements of hospital and Medicare quality measures and value-based purchasing to acquire and maintain preferred provider status.

Clinical Analytics

Our team completes a comprehensive risk assessment on every patient within 48 hours of admission to a skilled nursing facility or home health agency and we make our analysis and risk dashboard immediately available to the entire nursing team. We continue to analyze all vitals and nursing notes to build our knowledge of each patient and prepare our care team to manage all their aftercare needs. We recognize there is more involved than analyzing health vitals and profiles to predict a patients’ risk profile. The aftercare success or failure is often determined by all of the existential factors that can contribute to a readmission. We are experts in identifying the environmental, social, and personal characteristics that make some patients a higher risk for readmission than others.

Aftercare Supervised by OverSightMD Physicians

doctor-supportThe continued successful recovery of every patients directly reflects upon each skilled nursing facility and home health agency as part of the care continuum. Many patients have complex health issues that only a highly experienced team of physicians can identify. All patients receive diligent reviews by the OverSightMD physician team through regular scheduled wellness assessments. OverSightMD physicians interpret all assessments and direct our care team representatives to identify acute related concerns early and verify that the appropriate care plans are in place for the patient by their PCP and ancillary care providers.

Primary Care Physician & Care Team Updates

team of care providerPositive health outcomes combined with high patient satisfaction requires every care provider to be on the same page so patients focus on healing not navigating the healthcare system. Our care teams make sure that no one involved in a patients’ care is left out of the loop. We will inform all care providers and stakeholders when the patients’ status changes and provide real-time updates and analysis through our web portal to maintain transparent communication.

Aftercare Care Coordination and Advocacy Support

senior_1We take patient satisfaction seriously. Our care team representatives make sure that no patient is left to fend for themselves trying to get medical appointments or care providers to take a health concern seriously. We have trained professionals that are available to comfort patients in their time of need and directly assist them to navigate the healthcare system during their critical recovery period. If a care provider is not able to accommodate the needs of a high-risk patient, then we will advocate for the patient to obtain the care that is needed.

Point of Care Analytics

Point of Care AnalyticsTransparent communication across the entire care continuum is our focus. We have extensive data sharing capabilities to easily collect patient information from skilled nursing and ancillary service providers to provide continuous oversight support. We can train any care provider within 15 minutes on how to report patient vitals and notes back to OverSightMD in real-time, while at the point of care. This real-time exchange of information about a patients’ status is unprecedented and allows our team to be virtually in the room with the home healthcare nurse or caregiver to provide decision support and expedite primary care physician involvement if needed. In addition, all patient activities are documented and shared with all providers and stakeholders in real-time which eliminates the long delays in information being shared.

Clinical Decision Support

decision-supportThe success of a patients’ aftercare recovery is dependent on the quality of the hand-off at the time of discharge from acute or sub-acute care. We have extensive protocols in place to start aftercare preparations and coordination at the time of admission to a sub-acute facility. Risk stratification, patient vitals analytics, nursing notes, and observation reviews allow us to develop a clear plan of action. Our care team and physicians continue to closely track each patient and aggregate all critical information that is made easily available and communicated to ancillary care providers during the discharge planning process, transition of care and for the remaining time of the bundle period.

Care Plan Oversight & Management

Your Own Medical TeamWe are dedicated to ensuring quality of care for all patients. When patients, family members, and caregivers execute the care plan that has been designed by their primary care physician, successful outcomes are achievable and readmissions are avoided. We engage with patients and caregivers on a regular basis to complete a wellness assessment to determine if the patient is recovering on schedule or additional support is needed. If our assessment uncovers an early sign of an acute problem with a patient, we notify the patients’ primary care physician or home healthcare provider to quickly address the issue. We continue to engage with the patient to verify that a clear care plan is in motion and responsive care is being provided. We will continue to coordinate care for the patient until the acute issue is resolved and the patient is stable.

HIPAA Notice

Your Information. Your Rights. Our Responsibilities.

This notice describes how protected health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:

  • Get a copy of your paper or electronic record
  • Correct your paper or electronic record
  • Request confidential communication
  • Ask us to limit the information we share
  • Get a list of those with whom we’ve shared your information
  • Get a copy of this privacy notice
  • Choose someone to act for you
  • File a complaint if you believe your privacy rights have been violated

Your Choices
You have some choices in the way that we use and share information as we Market our
services

We may use and share your information as we:

  • Provide oversight services concerning you
  • Coordinate your care, including with your doctor and third­party service providers
  • Payment
  • Run our organization
  • Bill for your services
  • Help with public health and safety issues
  • Do research and analysis
  • Comply with the law
  • Work with a medical examiner or funeral director
  • Address workers’ compensation, law enforcement, and other government requests
  • Respond to lawsuits and legal actions

When it comes to your health information, you have certain rights. This section explains
your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

  • You can ask to see or get an electronic or paper copy of your personal health information we have about you. Ask us how to do this.
  • We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost­based fee.

Ask us to correct your medical record

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
  • We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

  • You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
  • We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

  • You can ask us not to use or share certain personal health information for communications, care coordination, including with third­party providers, payment and care oversight and operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
  • If you pay for a service or health care item out­of­pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

  • You can ask for a list (an accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all the disclosures except for those about communications, care coordination, including with third­party providers, payment and care oversight and operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost­based fee if you ask for another one within 12 months.

Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive
the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
  • You must provide documentation, such as a power of attorney, to demonstrate that the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

  • You can complain if you feel we have violated your rights by contacting us using the information on page 1.
  • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1­877­696­6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
  • We will not retaliate against you for filing a complaint.

Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

  • Share information with others involved in your care
  • Share information in a disaster relief situation
    If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
  • Use information for marketing purposes

In these cases we never share your information unless you give us written permission:

  • Sale of your information
  • Most sharing of psychotherapy notes

Our Uses and Disclosures

How do we typically use or share your health information?
We typically use or share your health information in the following ways.

Treat you
We can use your personal health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization
We can use and share your personal health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services

Bill for your services / Payment
We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html .

Help with public health and safety issues
We can share health information about you for certain situations such as:

  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety

Do research
We can use or share your information for health research.

Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:

  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html .

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Other Instructions for Notice

  • Effective Date of this Notice is July 1, 2017
  • Privacy contact: compliance@oversightmd.com and (408) 890­7000.
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