Annual Wellness Visit (AWV)

The purpose of the AWV is to review the patient’s wellness and develop a personalized prevention plan. Humhealth Annual Wellness Visit image

1. Acquire Beneficiary information

  • a. Administer HRA
  • b. Establish the beneficiary’s medical/family history
  • c. Review the beneficiary’s potential risk factors for depression, including current or past experiences with depression or other mood disorders
  • d. Review the beneficiary’s functional ability and level of safety

2. Begin Assessment

  • a. Health Risk Assessment 1) CAGE Questionnaire 2) Activities of Daily Living 3) Instrumental Activities of Daily Living
  • b. Cognitive impairment assessment
  • c. PHQ-2 and PHQ-9 Depression assessment

3. Counsel Beneficiary

  • a. Establish a written screening schedule for the beneficiary, such as a checklist for the next 5 to 10 years, as appropriate
  • b. Establish a list of risk factors and conditions for which the primary, secondary, or tertiary interventions are recommended or underway for the beneficiary
  • c. Furnish personalized health advice to the beneficiary and appropriate referrals to health education or preventive counselling services or programs
  • d. Furnish, at the discretion of the beneficiary, advance care planning services
Humhealth awv screenshot

Key Features

  • Health Risk Assessment

    Health Risk Assessment

  • Cognitive impairment assessment

    Cognitive impairment assessment

  • PHQ-2 and PHQ-9 Depression assessment

    PHQ-2 and PHQ-9 Depression assessment

  • Functional Ability and Level of Safety

    Functional Ability and Level of Safety

  • Beneficiary Checklist for the next 5 to 10 years

    Beneficiary Checklist for the next 5 to 10 years

  • Auto Generation of Recommendations

    Auto Generation of Recommendations

HCPCS Codes and Descriptors

  • HCPCS Code
  • Billing Code Descriptors
  • Average Reimbursement

Behavioral Health Integration (BHI) Services

Integrating behavioral health care with primary care (“behavioral health integration” or “BHI”) is an effective strategy for improving outcomes for people with mental or behavioral health conditions.

Types of BHI Services

  • 1. General
  • 2. Psychiatric Coordinated Care Management (CoCM)

Care team members

  • 1. Treating (Billing) Practitioner
  • 2. Beneficiary
  • 3. Potential Clinical Staff

Service Components

Initial assessment

  • Initiating visit (if required, separately billed)
  • Administration of applicable validated rating scale(s)
  • Systematic assessment and monitoring, using applicable validated clinical rating scales
  • Care planning by the primary care team jointly with the beneficiary, with care plan revision for patients, whose condition is not improving
  • Facilitation and coordination of behavioral health treatment
  • Continuous relationship with a designated member of the care team

Principal Care Management (PCM)

Principal Care Management is also known as PCM and it is very similar to Medicare’s Chronic Care Management (CCM) with a few key differences. Under the new PCM codes, specialists may now be reimbursed for providing their patients with care management services that are more targeted within their own particular area of specialty. This program addresses the need for classification of treatment for patients with one chronic condition.

Transitional Care Management (TCM)

Humhealth Annual Wellness Visit image

Dashboard

Humhealth awv screenshot
  • Remote Patient Monitoring workflow 1

    1

    Discharged from Hospital

  • Patient Monitoring workflow 2

    2

    Interactive Contact

  • Remote Patient Monitoring workflow 3

    3

    Face-to-Face Visit

  • Remote Patient Monitoring Devices workflow 4

    4

    TCM Completed

TCM Workflow

Humhealth awv screenshot

4G Telehealth Gateway Hub

  • BP Monitor – 90 readings

  • Glucometer – 500 readings

  • Peak flow meter – 250 readings

  • BP with ECG (BP) – 50 readings

  • BP with ECG (ECG) – 10 readings

All devices can be taken along when a patient travels and the readings can be synchronized with 4G Telehealth Gateway Hub when the patient returns home.

  • Remote Patient Monitoring workflow 1

    1

    BP Monitor

  • Patient Monitoring workflow 2

    2

    Glucometer

  • Remote Patient Monitoring workflow 3

    3

    Weight scale

  • Remote Patient Monitoring workflow 3

    4

    Pulse oximeter

  • Remote Patient Monitoring Devices workflow 4

    5

    BP monitor with ECG

  • Remote Patient Monitoring Devices workflow 4

    6

    Peak flow meter

  • Remote Patient Monitoring Devices workflow 4

    7

    Thermometer

Coming Soon (Device Integration)

Smart BP moniter

Smart watch

Mobile App Features

Patient:

The goal tracking feature is available for the following modules.

  • Remote Patient Monitoring workflow 1

    Physical activities

    Step count, Walking, Yoga, Swimming, Aerobic, Bicycling, Running, Strength Training, playing Basket Ball and Soccer, Skipping and Climbing can be tracked.

  • Patient Monitoring workflow 2

    Healthy Eating

    Calories intake and Calories burned can be tracked.

  • Remote Patient Monitoring workflow 3

    Stress Management

    Stress management assessment can be done and the appropriate intervention can be recommended.

  • Remote Patient Monitoring workflow 3

    Sleep Management

    The duration of deep sleep and light sleep can be tracked.

  • Remote Patient Monitoring Devices workflow 4

    Water intake

    Based on the patient’s gender, age and weight, the water intake will be recommended.

  • Remote Patient Monitoring Devices workflow 4

    Healthy Weight

    It is mainly useful for the patients with high cholesterol and hypertension chronic conditions. Weight reduction goal can be set and tracked.

The mobile app can be used by RPM patients to take vital readings for Weight, Blood Pressure, Blood Glucose, SpO2, Temperature, Peak Expiratory Flow Rate and ECG through Bluetooth connectivity.

Patient Physical Activity
Patient Physical Activity
Patient Vitals Device
Vitals
Patient Weight
Patient Weight

Physician and Clinician:

The Physician and Clinician can view the details of the patients including care plan, Service summary along with the vital readings. Vital alerts are raised for the device readings which fall outside the normal range. The Physician can take appropriate action to ensure the patient’s well-being and close the alert.

Physician CCM Dashboard
Physician CCM Dashvoard
Physician RPM Dashboard
Physician RPM Dashboard
Physician Patient List with Search
Physician Patient list search
Physician recommendation by audio
Physician voice recording 1

Remote Therapeutic Monitoring (RTM) – Coming Soon

What is Remote Therapeutic Monitoring?

Remote Therapeutic Monitoring (RTM) manages patients using devices that collect non-physiological data also called as therapeutic data. As per CMS guidelines, therapeutic data include pain levels, medication adherence, and therapy adherence as recorded or reported by the patient via a medical device. Both respiratory and musculoskeletal system status can be monitored through RTM.

Billing opportunity for Therapists

RTM is a very good billing opportunity for Qualified Healthcare Professionals (QHCP) such as physical therapists, occupational therapists, clinical psychologists and registered dieticians.

4

Musculoskeletal therapy

Musculoskeletal disorders which affect some of the parts of the body like upper and lower back, neck, shoulders, and extremities (arms, legs, feet, and hands) can be treated through Humhealth RTM solution.

Respiratory therapy

Humhealth can assist in the treatment of respiratory diseases like Asthma, chronic bronchitis, bronchiectasis and Chronic Obstructive Pulmonary Disease (COPD).

Key differentiators

  • Remote Patient Monitoring workflow 1

    Pricing Transparency

  • Patient Monitoring workflow 2

    Device Quality

  • Remote Patient Monitoring workflow 3

    Prompt Customer Support

Humhealth is planning to launch Remote Therapeutic Monitoring (RTM) very soon.

Billing Codes

  • CPT Code
  • Billing code Description
  • Average Reimbursement