T he mission of this white paper is to demonstrate to the reader, via a real- life use case and its outcomes, that it is practical and possible to have a significant positive effect on health outcomes for people with life-threatening conditions, such as heart failure, while reducing healthcare costs to both patients and providers. This is achieved by applying an evidence-based behavioral science and telehealth system of remote care that simplifies the ability of patients and clinicians to achieve their desired goals. For centuries, clinicians have applied their craft by evaluating patients (either in person or more recently via televideo), reaching a treatment decision, and providing a care plan with instructions that may or may not include medications. It is always the hope and expectation that patient adherence to clinician instructions and care plans extend well beyond their 15 to 30-minute appointments and follow-up calls. In the last decade, telehealth and digital healthcare have been expanded and refined, but without sufficient patient input or
consideration for patients’ psychosocial states and lifestyle factors. Many provider organizations have implemented patient portals, apps, and appointment reminder software that have not, for the most part, improved adherence or outcomes, while costs and adverse events continue to increase. In this white paper, you will discover telehealth clinical and operational insights and best practices that have achieved the Quadruple Aim. A primary goal for achieving success is for care teams to become more (cognitively) present in the minds of patients as they go about their activities of daily living on their own terms, and to create a patient-partnered care plan that dynamically adjusts to patients psychosocial and physical states, making it much more likely that they will stay on course and activate the behaviors necessary to achieve their health goals. This integrated approach has also shown the following benefits to provider organizations: reduced clinician fatigue, increased joy in practice, scaled population served with same FTEs, and increased community referrals. Further, in today’s value-based payment structure, practices can experience increased reimbursements, increased opportunities to obtain shared savings dollars for hospitals and practices, and avoidance of potential penalties for excessive ED visits and hospital readmissions.
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