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Chronic Disease Management

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Chronic Disease Management

At Maxlink Health we have created a robust Chronic Disease Management program with our experienced and proven CareTeam365. The most common diseases where Patient Monitoring has proven improved outcomes include CHF, COPD, Diabetes, Hypertension, Stroke and Chronic Renal Failure. We offer innovative programs that will support any chronic condition. Patients often have more than one chronic condition so support for co-morbidities is crucial.

Medication Management

High risk population management

  • Ensure that patients are not discharged with medication errors.
  • Integrate medication education as per Physicians instructions to maintain medication adherence post discharge from hospital.
  • Provide patient education that adheres to health literacy standards to improve patient comprehension and retention of medication management related knowledge especially for those with greatest risk of non-compliance (low health literacy and numeracy).
  • Embed a "Teach-back Process" to validate patient and/or caregiver comprehension of the medication management related information provided.
  • Provide low-literacy aids to augment learning with tools such as text messages, and/or daily medication reminder phone calls.
  • These interventions are not only meaningful for the clinical outcome improvement results they can provide, but they are also aligned with safety, regulatory standards, and compliance standards that lead to higher reimbursement payments. These incented standards range from reduction in readmissions related to medication management events, to attestation for Meaningful Use Stage II criteria for integrated patient education and improving patient satisfaction scores as evaluated by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

Reduce readmissions

  • Maxlink CareTeam 365 provides patient monitoring, education and engagement with 100% of discharged patients, regardless if they are discharged to their home, or to the care of a home health agency or to a Skilled Nursing Facility.
  • Hospitals are financially at risk for following up with recently discharged patients to prevent unnecessary readmissions. Timely and thorough follow up helps reduce readmission, improve patient satisfaction, reduce patient stress and improve overall quality of care.
  • A cost effective way to proactively engage and interact with patients to improve care and reduce costs.
  • Monitor chronic conditions to prevent hospitalization, re¬-hospitalization and emergency room visits.
  • Encourage self-¬management.
  • Educate and inform employees with long term and chronic conditions.
  • Promote wellness initiatives.
  • Support compliance with rehab, wellness, and discharge plans.
  • Reduce out of pocket expenses through better awareness, early detection and early intervention.
  • By actively monitoring at risk members, it is possible to reduce the need for hospitalization or emergency treatment thus helping to reduce costs in the healthcare delivery system.