CARE MANAGEMENT PROGRAM ACCELERATION
Lightbeam’s care coordination services help improve clinical and financial outcomes for patients
living with chronic conditions.
SCALABLE CARE MANAGEMENT PROGRAMS
Having patients engage and participate in their individual care plans is critical to a value-based care organizations’ revenue, costs, and sustainability. While leveraging a population health solution is key for success in value-based care, lacking care management resources and staff might hinder your ability to make the impact you desire. This is where Lightbeam care coordination services come in.
FULL-SERVICE CARE COORDINATION SERVICES
Our clinical care team can administer activities on your behalf to improve patient care and reduce the need for costly medical services by helping patients and caregivers more effectively manage health conditions. Lightbeam’s care management services act as an extension of your team by facilitating collaboration among all clinicians, including regular patient communication, education, proactive engagement, early identification, and more.
Lightbeam provides you with a custom model to fit your care management needs. With our care management extension services, you can outsource all or a portion of care management activities, or we can help cover care management activities until you are able to build an internal program.
Lightbeam currently provides care management services for CMS covered programs, including AWV, CCM, and TCM
Annual Wellness Visit
A Medicare-based program designed for providers to perform annually for patients. In this visit are key items that include preventive services, health risk assessments, and more.
Chronic Care Management
Medicare has several care management programs designed to support patients with two or more chronic conditions in achieving an improved quality of life.
Transitional Care Management
A Medicare-based program designed to support patients who have recently been discharged from an inpatient setting to decrease the likelihood of readmission.
CARE TEAM EXTENSION IMPROVES PATIENT HEALTH OUTCOMES
In value-based care, you are responsible for all patients. In a year, you might see between 600 to 800 patients of the total 1,5000 to 2,000 attributed to you. We can help monitor them to reduce hospitalizations and ER visits, and improve health by engaging patients on a frequent basis.
Care Team Extension Benefits
Connect the full care team. Having all the available information helps build the most impactful treatment plan. At Lightbeam, our team will centralize your data and reach out to all care team members.
Communicate with patients. Dedicated clinical staff will speak with patients on a regular basis to obtain current statuses, review treatment plans, provide education, and review progress between office visits.
Coordinate supporting services. Treatment plans for patients can involve several steps. Our team will coordinate appointments and any service needs for a higher rate of compliance.
Explore The Services That Help Our Clients Save:
Care managers using Lightbeam to make life-changing impacts on their patients
After a hospital admission, I used Lightbeam’s cohorts to identify and contact a patient admitted to the hospital the day before. They had a history of gastroesophageal reflux disease (GERD), hypertension, vertigo, and reported metastatic colon cancer after colon resection. The patient went to the hospital due to significant weakness, fatigue, decreased intake of food and fluids, and difficulty performing basic activities. After their stay, the patient was discharged with home health in place. Unfortunately, the patient lived alone with no immediate family in the area and only one friend who would check in a few times a week. After determining the patient could not care for themself post-discharge due to increased weakness, I contacted them to create a care plan and complete a successful transition of care into their skilled nursing facility (SNF) of choice. The patient and their friend were very grateful for all the work we did to ensure a safe environment with access to care, and Lightbeam’s notification of admission accelerated what would have been a much longer process.
I was helping a high-risk patient after they were discharged from a stay in the hospital. The patient had a list of diagnoses, including type II diabetes, chronic kidney disease (CKD), chronic obstructive pulmonary disorder (COPD), coronary artery disease (CAD), multiple myeloma, arthritis, and anxiety. Using Lightbeam’s Care Management module, I created an individualized care plan and documented every service performed right in the patient’s profile. I called the patient and their spouse regularly every 3 to 4 weeks to check in. I learned that the patient’s spouse had difficulty determining the right foods to prepare for people that manage diabetes and renal problems. On top of that, the patient was having trouble swallowing. I discussed my proposed care plan with the patient’s physician, and they agreed that it was important to speak to a nutrition and diabetes education specialist. After learning helpful ideas for snacks and meals, the patient and their spouse feel more confident to manage their health at home and engage with me during follow-ups.
My particular role is to help patients and their families after discharge from hospitals or skilled nursing facilities. When I think about how much Lightbeam has helped me determine which patients need intervention the most, a particular situation comes to mind. Leveraging Lightbeam’s Care Management tools, my colleagues and I saw a patient in their 90s that was frequently admitted to the hospital. This patient’s only immediate family was their daughter, who lived out of state. I contacted the patient and their daughter and became their point of contact if they had any questions or concerns before going to the hospital automatically. The daughter called me daily, and we would review medications, help set up home health services, and eventually set up hospice care. I truly love being a care manager and impacting patients in positive ways like this, and Lightbeam simplifies the process greatly.
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