Empower chronically-ill patients by giving them access to a patient-centered care team that promotes self-care and targets behavior-change objectives to transform health outcomes.

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About Care Management Services

Care Management services allow complex patients to receive care on a patient-centered continuum. Patients with chronic issues enrolled in these programs see improved health outcomes thanks to ongoing care coordination, continuous connection to their providers, and pre-scheduled telehealth visits.
  • Chronic Care Management (CCM): Targeted Care for Patients with Chronic Diseases
  • Behavioral Health Integration (BHI): A Patient-Centered Approach to Mental Health for a Defined Population
  • Psychiatric Collaborative Care Model (CoCM): Psychiatric Consultation Integrated with Primary Care
  • Transitional Care Management (TCM): Proactive Follow-up Care for Recently Discharged Patients

Care Team Involved

  • With a Medical Director (35+ years of experience) and ARNPs on hand, Certintell’s Certified Health Coaches are overseen as care coordination is provided to the patient in the comfort of their home while engaging clinic staff on any changes to the evolving care plan.
  • Network of Specialty Physicians (as directed) 
  • The Beneficiary as an Integral Member to Care Team
  • As required by CMS, our solution goes beyond telephonic to cover all of your CCM needs; including asynchronous secure messaging, video calls, and Remote Patient Monitoring (RPM)

  • Certintell’s virtual medical team oversees all of the beneficiary’s care, including the ongoing oversight, management, collaboration and reassessment.

  • Real-time care plan and time tracking shared between our Certified Clinical Health Coaches and the health center’s internal care team.

  • Care planning by the primary care team, jointly with the beneficiary, with care plan revision for patients whose condition is not improving adequately. Treatment may include pharmacotherapy, psychotherapy, and/or other indicated treatments.

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