Chronic Care Management CCM | HIHealthSystem

Holon Inclsive Healthcare knows Collaborative Care and Primary Care Integration:

Proving the evidence proving the effectiveness of Collaborative Care, health system leaders are looking to adopt this innovative model. Holon Inclusive Health System can make it easy, providing an out-of-the-box solution to roll out a functional operation quickly.

With 1:1 and group meetings, we can help your primary care team understand and embrace a team-based approach to treating mental illness confidently. We can help you select and train personnel and set up effective processes and procedures, right down to supplying the forms and documentation templates, as much or as little as you need. Even better, if you don't feel like doing any work other than directing the behavior health managers to check in on your patients using a set protocol; they can do that too; making the process even more simple and easy for you and your patients.

Holon Inclusive Health System can help you understand the coding and billing process to make sure this valuable service is fully covered by insurance, and we can help you set up a strategic plan to develop the triage, therapy and medical management “bench” to fully cover all your patients’ mental health needs through our Collaborative Care and Behavioral Health Integration.

 

Collaborative Care And Primary Care Integration:

  • Utilize bachelors level Humanities graduates to conduct psychiatric interviews

  • Have your primary care patients seen faster than waiting on a specialty referral

  • See more patients through Chart Reviews versus traditional office visits

  • Integrate into Primary care offices within your organization, or utilize to expedite your specialty office’s wait lists

  • Certified Psychiatric Assistants can help your Psychiatrists maximize their billing potential.

  • Documentation and Billing Support: We directly document into the medical record when possible on your behalf.

  • possibilities through Medicare COCM collaborative care models

  • Utilize APA approved outcome measures to track patient progress

  • Utilize state of the art technology to keep in contact with your Behavioral health manager and your Psychiatric Consultant

  • Utilize HIPAA compliant texting in real time that connects the entire team - you, your patient, the behavioral health manager, and the psychiatrist on one platform.

  • Utilize cutting edge information like psychopharmacogenomics, nutragenomics, integrative psychiatry and other personalized medicine techniques with the specialty backgrounds that you are afforded being connected with Holon Inclusive Health System Specialty Providers.

  • Your patients will have access to specialty applications to monitor their conditions using the lates mTechnology!

  • There are 75+ trials supporting Collaborative Care. As we treat behavioral health, you’ll see other problems get better. Studies have demonstrated improvement in LDL, A1c and blood pressure. Our experts will translate the evidence base to your practice

  • No upfront expenses for providers

  • Drive better outcomes- continuously monitory high risk patients including high risk seniors in your population.

  • White glove onboarding. We handle patient outreach, enrollement, device setup and support.

  • We provide complex care management to populations with the following conditions:

  • Chronically medically ill ages birth to death

  • Intellectual/Developmental disability

  • Severe and Persistent Mental Illness

  • Substance Use Disorder

  • Transgender

  • Foster Care Children

  • Members in Medicare ACO

  • Members transitioning from facility to home

  • Members with a priority score that indicates they most likely will benefit from complex care management

  • Traumatic Brain Injury

  • Social Determinants of Health Assistance: experience connecting patients to much needed resources as part of their whole health care. Our care managers screen for social determinants such as food scarcity, affordable housing/housing safety, transportation concerns, toxic stress/interpersonal violence, and inability to purchase health care tools that would be a barrier to increased health outcomes. Our team also ensures those patients are linked to a provider. Holon Inclusive Health System can receive referrals from practices and other community partners which we can then determine if they are eligible for care management services.

  • Clinical pharmacy support due to an increase of high-risk, blind, aged, and/or disabled patients with diverse medication profiles and prescribers, making them prone to multiple medication-related problems. Our pharmacy relationship goals emphasize improving global patient outcomes and decreasing overall health care costs. Holon Inclusive Health pharmacist affiliates, care managers, and providers work together to deliver patients the best care possible.

  • We do this providing:

  • Medication Reviews upon initiation, transitions and medication changes

  • Support to optimize patient adherence

  • Patient education on wellness and preventative efforts, disease and medications, self-management and follow-up support

  • Certified Diabetes Educator (CDE) support

  • Support to practices with best practice education (including Opioid-related efforts) and multi-payer prior authorization issues

  • Practice support with pharmacy-related care gap closures

  • Medication Management in collaboration with provider

Phone: 844-902-2554

Fax: 833-914-0432

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