Healthcare Comes Home Program

Healthcare Comes Home with Connected Care aims to reduce or eliminate the barriers to health care.

In a significant effort to enhance healthcare accessibility and improve the lives of patients, the Three Rivers Area Medical Associates’ medical team has developed a comprehensive suite of remote services under its Health Care Comes Home program.

These bundled solutions cater to individuals managing chronic conditions, especially those living alone or with an elderly spouse or caregiver, lacking regular access to healthcare and often without reliable transportation to and from doctor’s appointments.

Particularly for patients living alone and struggling with transportation limitations that limit access to healthcare, the impact of these offerings is profound. By combining medical care with technology, transportation, community and social services and food and nutrition, Three Rivers Area Medical Associates has ensured that no one is isolated or left without essential care.

The Health Care Comes Home Toolbox: A Multifaceted Approach

1. Spruce Secure Patient Communications Portal

Spruce is the #1 app for healthcare communication, and it’s 100% free for patients and is available on iOS, Android and Web applications.

Patients want more access to care and digital convenience, as well as the ability to securely message their providers and care teams. Spruce powered by mHealthQuest helps to make quality healthcare more accessible regardless whether you are at home, at work or on the go.

Learn more about your Spruce Secure Patient Communications Portal

2. Video Telehealth Visits

Video telehealth appointments have become the cornerstone of patient-provider interactions. These virtual face-to-face consultations allow healthcare professionals to assess outward physical symptoms, answer patient questions, and provide access to medical care outside the four walls of the clinic.

Here’s how they benefit patients:

• Follow-up Appointments: Patients receive follow-up care after dietary modifications, medication adjustments, or lifestyle changes.
• Telehealth Care for Chronic Conditions: Individuals dealing with conditions such as health failure, cancer, rheumatological diseases, diabetes, and migraines can engage in routine check-ins to stay current with the management and treatment of their conditions.
• Test and Imaging Result Explanations: Providers discuss test results with patients remotely and answer questions when Telehealth video visits are an appropriate option.

Learn more about video telehealth visits

3. Chronic Care Management (CCM) benefits patients with one or more chronic conditions and provides care in between doctor’s appointments from the comfort of home or work

CCM services are designed to provide care coordination for patients with multiple chronic conditions expected to last at least 12 months.

 CCM services can be delivered in a variety of locations outside the provider’s office, including community and in-home settings, by telephone, and online. Services may also include contacts with other providers to coordinate care, as well as including your caregivers in your care process. This care is provided by a dedication health coach as well as your doctor.

Provided remotely directly to patients and their caregivers at home, Chronic Care Management can benefit patients with multiple chronic conditions in several ways, including improving care coordination with necessary third-party specialists and free community services, and decreasing the risk of long-term medical complications.

Some of the benefits of chronic care management include: 

Better engagement with your healthcare professional and monitoring of your conditions  

Patients are more engaged in their care when they have access to chronic care management services. They are more likely to achieve their health goals, which can lead to reduced stress, improved mobility, and better sleep. 

Improved outcomes and access to care 

Chronic care management services can help patients manage their chronic conditions more effectively, which can lead to improved health outcomes. Patients who receive chronic care management services are also more likely to have access to care when they need it.

“Secondary insurance plans such as AARP often pay patients Medicare deductibles and copays.”

 Secondary insurance plans such as AARP Medicare Supplement Plans can help pay for Medicare deductibles and copays. These plans are designed to cover some of the gaps in Medicare coverage, such as copays, coinsurance, and deductibles. Each plan varies in terms of coverage and cost, and the cost you pay may be determined by your location. As you are deciding to enroll in a CCM program, we can find out what your primary and secondary insurance plans will pay for the program.

The Qualified Medicare Beneficiary Program also helps pay for Part A and Part B premiums, deductibles, coinsurance, and copayments. If you qualify for this program, you also automatically qualify for the Part D Extra Help program and pay no more than $4.30 in 2023 for each drug your plan covers. We will connect you to the Michigan MMAP financial assistance and counseling team in our area for help in finding out if you qualify for this and other financial assistance programs.

4. Personal Health Coaching

Personal Health Coaching is an effective technique offered as a part of Healthcare Comes Home and Connected Care that works remotely through regular telephone visits, and connects patients to their providers, specialists and other health related services as well as helping patients self-manage chronic conditions.

Here is how it works:

How Personal Health Coaching Works:

• Health coaches bridge the gap between in-office visits by continuously monitoring and assessing patients’ conditions.
• Health coaching can be delivered remotely, making it healthcare accessible to vulnerable groups.
• With regular remote encounters, health coaches keep patients focused on taking their medications and report to the doctor any problems that need immediate follow-up by the in-office care team.
• They help patients navigate the healthcare system, understand their conditions, and make informed decisions.
• Health Coaches work with patients to identify what is important to them, set health-related goals, and provide education and support to achieve those goals.

Personal Health Coaching and You

“Patients enrolled in Personal Health Coaching programs have a  1:1 relationship with their personal health coaches over the phone”

The relationship between patients enrolled in a chronic care management or other personal health coaching program and their Personal Health Coaches - and how often they engage - can vary depending on the patient's needs and the care plan developed by the health care provider.In many programs there is no cost, and the cost of speaking with your coach multiple times per month, if any, is no more that only engaging with the Personal Health Coach once a month.

Patients inPersonal Health Coaching and chronic care management programs always have the option of calling and speaking with their personal health coach as needed to discuss new information about their health including symptoms, changes in health status, changes in caregiver arrangements, transportation issues, ED visits and hospitalizations and more.

Using phone technology to communicate with patients on a regular basis is an area of growing importance in healthcare as it enables convenient patient care and follow-up at lower costs than the status quo health facility, especially for patients who live in rural areas or need follow-up between visits to manage chronic conditions. In these cases, receiving care from a qualified professional over the phone or by secure messaging from your smartphone can be enormously beneficial

A typical patient’s experience with Personal Health Coaching

When a patient faced diabetes-related challenges, Dr. Patel and the patient’s Personal Health Coach assigned through their specific program discuss solutions. Together, Dr. Patel and the Personal Health Coach map out blood sugar patterns, adjust medications, discuss other aspects of the care plan.

In meeting with the patient, Dr. Patel discusses the important factors related to diabetes and explained the steps needed to combat the disease and the available care pathways.

Every month at least, the patient’s Personal Health Coach makes phone calls. “How are you today?” The patient also calls the Personal Health Coach if there were any questions or anything new to report. All month long, the patient is monitored by the Personal Health Coach and Dr. Patel's care team for blood glucose numbers. Dr. Patel is regularly informed of these encounters with the Personal Health Coach and the patient's blood glucose readings.

The Personal Health Coach reminds the patient to celebrate small wins—a flight of stairs climbed, a sugar-free dessert savored.

5. Remote Patient Monitoring (RPM)

Advancements in technology have revolutionized chronic care management. RPM enables patients to monitor their health conditions from the comfort of their homes, reducing the need for frequent office visits.

Key features include:

• Symptom and Vital Sign Tracking: Patients use wearable devices to transmit real-time data to their healthcare providers.
• Covered by Insurance: Certain RPM services are now covered by Medicare, Medicaid, and private insurers.

6. Non-Emergency Medical Transportation

For patients without reliable transportation, accessing medical services can be challenging. By engaging NEMT services, your Personal Health Coach connects with dedicated drivers offer door-to-door transportation for non- emergency medical appointments, ensuring that no patient is left behind in their quest for medical services.

Transportation Services for Seniors

Non-Medicare transportation services are also available for seniors who require transportation but might not meet Medicare’s criteria for receiving transportation benefits. Your city may have a local Area Agencies on Aging office nearby to help you find these services in your area. This office can help anyone aged 60 and over with gaining access to transportation.

They may recommend commercial transportation options like:

• Senior Transportation Programs offered by local-area governmental services such as St. Joseph County Transportation Authority
• Lyft 
• Uber
• Area Wide Transport (Schoolcraft)

These companies have specialized healthcare pricing to help you get to and from doctors’ appointments to improve access to healthcare services in the immediate area.

Does Medicare Advantage Provide Free Transportation to Medical Appointments?

In recent years, the Centers for Medicare & Medicaid Services (CMS) gave privately-run Medicare Advantage carriers more flexibility to expand supplemental benefits to include ridesharing options.

If you have a Medicare Advantage plan and are unsure if it covers medical rides, contact your insurance carrier or check with your Personal Health Coach who will help you find out.

Several Medicare Advantage plans now offer innovative benefits to Medicare enrollees, including transportation services. Depending on your plan, you may have to use a certain transportation company, or you could receive reimbursement for using travel alternatives.

7. Landmark Health Mobile Care Team

For patients with qualifying chronic conditions and without reliable transportation, accessing medical services can be challenging. Three Rivers Medical Associates’ mobile healthcare team, sponsored by Landmark Health, bridges this gap.

Landmark Health focuses on complex, chronic patients and fosters collaboration among providers, specialists, and families.

What is Landmark Home Services and how does it work for patients who are homebound?

Landmark Health is a healthcare organization that specializes in providing in-home medical care for patients with multiple chronic conditions. Here’s how it works:

1. House Calls and Video Visits:
• Landmark’s team of providers, including doctors, nurse practitioners, and physician assistants, make house calls to patients’ homes.
• They also conduct telemedicine visits via video and phone.
• These visits allow patients to receive medical care without leaving their homes.

1. Eligibility and Coverage:

• Patients living with chronic health conditions may qualify for Landmark services through their health plans.
• Landmark partners with health plans to improve access to care.
• The program is often available at no cost to patients.

1. Collaboration with Existing Providers:

• Landmark coordinates care with patients’ primary care providers, specialists, and other community resources.
• Patients can continue seeing their trusted providers while benefiting from Landmark’s added support.

1. 24/7 Support:

• Landmark’s provider-staffed call center is available round the clock.
• Urgent visits are provided to help patients avoid unnecessary trips to the emergency room.

1. Benefits:

• No waiting rooms: Patients avoid transportation to clinics and hospitals, as well as exposure to germs.
• Reduced stress: Landmark provides comprehensive care, addressing both medical and social needs.
• Improved well-being: Patients can feel better and stay well in the comfort of their own homes.

With over 500,000 patients nationwide, Landmark is committed to delivering high-quality care to patients who qualify, and these dedicated professionals provide in-home services that are paid 100% by some BCBS and United Healthcare insurance plans. Click here to find out if you qualify.