Give Your Home-Based Care Program a Leading Edge with the Right Technology

doctor using computer with tech graphics

If you have implemented a home care medical model or are moving your practice in that direction, your profitability depends on having effective systems and high-level insights. You need technology solutions that improve your ability to manage care without adding administrative burden to your staff. In this article, edited from an earlier one published on Acclivity Health Solutions’ website on June 8, 2021, we review five important ways that technology can help you track your patients’ health status, monitor and schedule care appropriately, and utilize your resources efficiently.

ai-icon  1. Predictive Analytics Help Ensure Proper Level of Care

One of your primary goals is to match the level of home care with the changing physical, emotional and social needs of your patients and their families. This can be difficult when you rely solely on feedback from these individuals.

Predictive analytics is an important development in advanced care management, working to solve the knowledge gap. Specialized tooling that combines claims and real-time patient data, Artificial Intelligence, and machine learning can help you determine the current care needs of patients with advanced illnesses and predict when they may need a higher or different level of care.

There are multiple benefits to a technology platform that includes predictive analytics. Most importantly, it can be used to identify patients in your community who can benefit from palliative or hospice care sooner. It can also help you anticipate changing staffing and equipment requirements and schedule staff and other resources in a more consistent way that reduces staff burnout and improves quality scores for value-based care contracts.

real-time remote monitoring icon2. Real-Time Remote Monitoring Creates More Connected Healthcare Ecosystem

Use technology to assess a patient’s condition remotely and alert you when indicators predict a patient needs additional care. A real-time monitoring system should enable the patient, their proxies, and/or your staff to complete data entry at the point of care. It may include the ability to track symptoms and vital statistics so you can assess a patient’s current condition and pinpoint whether they are stable, need more monitoring, or are nearing the end of life. When your data lives on a shared platform that everyone can access, you empower the entire care team to work together to improve care coordination and communication.

Real-time remote patient monitoring not only keeps clinicians connected with patients and their families between visits, it can also be used to assess for signs of caregiver breakdown and determine when to intervene and provide caregiver support.

phone alert icon3. Event Notification Helps Contain Costs

Most value-based care contracts penalize you for over-utilization of treatments and services. In order to prevent unnecessary hospital utilization or readmissions, you can use technology to ensure that your patients or caregivers call you first when they require care for an emergency that can be handled at home.  

There will be times when patients panic and call 911. With an electronic alert system in place, you can ensure you remain their primary care provider by being notified in real-time when a patient of yours enters or is discharged from an Emergency Department or hospital or transitions between levels of care.

telemedicine phone doc icon4. Telemedicine Connects Patients with Clinicians

The COVID-19 pandemic accelerated the use of telemedicine across the care continuum. Telemedicine has allowed home care medicine doctors and staff to stay in frequent contact with patients and families securely and safely. As the pandemic wanes, telemedicine will likely remain an effective way for clinicians and patients to interact. While renumeration for telemedicine visits post-COVID is still uncertain, CMS has acknowledged it will most likely continue to support it.

Offering telemedicine options may require additional education for both staff and patients who are not familiar with the technology. You can minimize the amount of training required by investing in programs that are intuitive and offer step-by-step guidance.

doctor on computer screen icon5. Family And Caregiver Education

Patients with advanced illness may be facing a terminal prognosis that qualifies them for palliative care or hospice.  The success of hospice depends on how well patients and their families accept their prognosis and understand the way hospice care works. Video and audio programs as well as interactive education modules can help you guide them through the process associated with the end-of-life journey — from diagnosis to defining goals of care to options for end-of-life care. Remote learning can also help caregivers learn the triggers and indicators to report so your staff gets a more accurate view of the patient’s condition.
Now is the time to implement technology to assist with care monitoring and management, scheduling, staffing, communications, patient education, and cost control. With the right technology, your organization can position itself to operate more efficiently and remain profitable.

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Learn more about Acclivity Health here.

Patient Education: Education for the individual with multiple chronic illnesses on medication adherence and management

It is common for individuals with COPD to have multiple comorbidities. Along with this comes the necessity, in most cases, to see numerous physicians. The opportunity for mismanagement of the individual described here is great. One physician may focus solely on glucose levels and insulin or diabetes medication to prescribe or change. Another physician could be focused on blood pressure and manipulating the dosage of the medication used to treat this disease. This myopic focus can lead to mismanagement of the individual as a whole.

So, what is the solution? Or rather, how can we minimize the risk of such medication errors or mismanagement? We can educate these individuals with best-practice tools and resources. This is a vital part of patient engagement.

doctor and patient reviewing charts

Some of the chronic diseases which are of highest risk for medication error are, but not limited to:

  • COPD
  • Congestive Heart Failure
  • Diabetes
  • Hypertension
  • Depression and/or Anxiety
  • Chronic Kidney Disease
  • Heart Disease
  • Osteoporosis
  • Osteopenia

Educate patients to use these best practices

  • Work with the primary doctor to decide what matters most when it comes to care. Remember that patients can choose which treatments they want and don’t want. Think about these questions and talk to the doctor about:
    • Which health problems are the most bothersome? Which one should be focused on first?
    • What matters most: living a long time, staying independent, or having the least amount of pain or other symptoms?
    • Are any of the treatments causing side effects or problems?

  • Plan for doctor visits ahead of time. When seeing the doctor, make a plan for what to discuss and come prepared with notes or questions. Do not try to do too much at once. If necessary, make more than one appointment.
  • Make sure the primary doctor, and any other doctor or nurse who prescribes medicines, knows about all of the medicines taken. This includes any over-the-counter or herbal medications used on a regular basis. It is helpful to take the actual bottles of pills to each visit, so the doctors or nurses can review them. Ask the main doctor or nurse to go over all medicines at least once a year.
  • Keep a list of all the medicines taken regularly that includes the dose taken, the reason for taking it, and the doctor or nurse who prescribed it. Keep this list on hand and take it to all medical appointments.
  • Ask the doctors and nurses which, if any diet or lifestyle changes would improve your health problems. Some of these changes may reduce the risks and side effects of some medicines or treatments.

There are things that all people can do to improve their health. Here are some examples:

senior man exercising on patio
  • Choose a diet rich in fruits, vegetables, and low-fat dairy products that is low in sweets and processed flours. For example, choose whole-grain bread and whole-grain pasta over white bread or regular pasta.
  • Do some sort of physical activity most days of the week, and build the activity level slowly. Even small amounts of activity done several times a day can help build strength.
  • Try to get enough sleep. For trouble sleeping, talk to the doctor or nurse about possible solutions.
  • For feelings of depression and anxiety, talk to the doctor or nurse. Depression and anxiety can make other health problems hard to manage.
  • Plan activities with other people, to avoid being stuck at home and alone for days. If friends and family are not around, look at the local paper for ways to meet new people through senior centers, religious groups, libraries, garden clubs, or other activity groups.

Patient Education for the Approaching Travel Season

As we approach warmer temperatures and a time when our patients are doing more travel, we can provide some best practice tips to ensure they have the knowledge needed to stay healthy. The following tips may minimize the risk of infections, sickness, and exacerbations while they are trekking through airports, tourist venues, and exposing themselves to unfamiliar airborne germs.

What if I am traveling internationally? Those traveling to Asia, Africa, South America, or Eastern Europe, should make an appointment at a travel clinic. The doctors and nurses there can help prepare for the trip. Depending on the destination, there might be a need to:

  • Have one or more vaccines, weeks, or months before the trip. For example, if traveling to parts of Africa or South America, a vaccine against yellow fever may be indicated.
  • Avoid ice, tap water, and certain foods or parts of foods that can carry germs. Drinking untreated water or eating certain foods may result in an infection that causes diarrhea, vomiting, or other problems.
  • Treat water, to make sure it has no germs that could cause infection. To get rid of bacteria, boil water for three minutes and then let it cool. Another way to eliminate germs is to take two quarts of water, add two drops of 5% bleach, and wait 30 minutes.
  • Use bug spray containing DEET or a chemical called picaridin. Wear clothes that protect from insect bites. Plus, check yourself for insects and remove them if found. Insects carry germs, and may cause infection when they bite or sting.
  • Take medicines before and during the trip to prevent infections such as malaria.
  • Wear shoes that cover the feet entirely if walking anywhere that dog or human waste may be present in the sand or soil. Places that do not have adequate plumbing or that do not treat toilet water before dumping it, result in contaminated soil. If walking barefoot in situations like these, it's possible to acquire a worm infection.

What if I have a health condition, but I want to travel? If you have an ongoing health problem, such as diabetes or heart disease, ask your doctor or nurse how to plan for your trip.

Many people with health concerns can travel without any problems. The key is to form a plan. Make sure to have all the needed medicines and supplies. It is essential to make a list of all the prescribed medications, the doses, and reason or associated diagnosis.

Here are some examples of individual travel needs:

elderly couple dancing on holiday
  • Some people with diabetes must carry pills, insulin, and syringes when they fly. They usually have a letter from their doctor explaining their needs.
  • Some people with lung or heart disease need extra oxygen when they fly. Because oxygen content in a pressurized aircraft contains less oxygen than room air at sea level, supplemental oxygen may be required by those with pulmonary issues. People who need oxygen on the flight must arrange it with the airline before they fly. A copy of the oxygen prescription should be kept on hand while traveling. Also, pre-planning with the HME provider is needed to ensure the availability of the necessary equipment required for travel.
  • Some people with blood clotting problems or bad veins need to stand up and move around if they are on a long flight. Otherwise, they can develop blood clots. They might also need to wear special stockings that improve blood flow in the legs.

Tongue Fat Volume and OSA

Obese patients with obstructive sleep apnea (OSA) are encouraged to lose weight, but the mechanism for improvement in OSA is unknown.

A recent prospective observational study of 67 obese patients with OSA compared the MRI of the upper airway before and after weight loss. The MRI measured airway size and tongue, pterygoid, lateral pharyngeal wall, and abdominal fat volumes. In the study, reduced tongue fat volumes was the primary mediator associated with an improved apnea-hypopnea index leading to the hypothesis that reduction in tongue fat volume may be a potential treatment strategy for patients with obesity and OSA.

Learn more about Incremedical here.

The Necessity of Auditing in Value-Based Care: Ensure Compliance and Optimize Revenue

Who in your organization is responsible for assuring your documentation and submitted codes are correct? Do you have an auditing process in place? If not, you may be assuming that thousands of ICD-10 codes submitted to the Centers for Medicare & Medicaid Services (CMS) are 100% accurate, which may not be the case.

Reimbursement models are changing. Historically, in fee-for-service payment models, the patient assessment in the EHR, coupled with the plan of care, helped identify underlying conditions, the impact of those conditions, necessary treatments, and a patient’s prognoses. In today’s value-based care models, healthcare entities assume financial risk, so the assessment, diagnoses, and ICD-10 codes influence payments, particularly since ICD-10 codes are used to generate a patient’s Hierarchical Condition Category (HCC) risk score. In all primary care models, Current Procedural Terminology (CPT) codes continue to be important, as they reflect the intensity of evaluation and management provided. However, ICD-10 codes, which indicate a patient’s disease state and the severity of such, have assumed center stage. The specificity and accuracy of diagnostic statements, along with assigned ICD-10 codes, directly affect the healthcare entity’s compliance program and revenue.

So, how do you ensure your documentation and codes are correct? Chart auditing:

1. Ensures compliance

Auditing can ensure that diagnoses and accompanying ICD-10 codes are substantiated, meaning there is reasonable evidence that each diagnosis exists, was addressed, and was supported. This is necessary for submission to CMS for risk adjustment purposes. Submitting incorrect codes, particularly if they map to a Hierarchical Condition Category (HCC), violates the False Claims Act. It is important to note that an incorrect code does not necessarily indicate that the provider’s diagnosis was incorrect, but rather the ICD-10 code applied was in error. Additionally, diagnoses cannot be submitted by themselves without demonstrating that they were addressed in some fashion during the encounter. Without proper training in documentation excellence, providers may inadvertently upcode conditions, generating HCCs that are not correct. Therefore, it is important to have consistent auditing practices in place. Identifying and redacting upcoding and incorrect codes demonstrates to CMS that you are looking, and compliance is a priority to your organization.

2. Assists with claims integrity

If claims data and various CMS reports are available, an auditor can ensure that all the ICD-10 codes generated from an encounter are in CMS’s possession for the purpose of an accurate risk score calculation.

3. Can increase revenue
With a comprehensive review of the encounter, an auditor can uncover diagnoses that may exist but were either not captured or only partially captured due to non-specificity. By reviewing labs, diagnostic imaging reports, and specialist consultations, an audit can present potential diagnoses that can be captured during a later encounter with that patient, leading to a more optimal risk score.

Though performing audits internally is acceptable, outsourcing auditing to an independent company improves your organization’s credibility. Capstone Risk Adjustment Services provides auditing solutions for value-based care healthcare entities. Our auditing services, combined with our physician-led Clinical Documentation Excellence (CDE) education, can greatly improve your organization’s compliance and revenue.

We are proud to offer AAHCM members a 5% discount on a 12-month subscription to our on-demand physician-created Clinical Documentation Excellence education course, CDE Online. To find out more about our auditing solutions or CDE Online, email us at [email protected], visit, or call 844-683-5302.



George “Mike” Brett, MD
SVP Consulting Services, Chief Medical Officer
Capstone Risk Adjustment Services

About George W. Brett, MD
Dr. Brett has more than 30 years of experience in geriatric medicine and long-term care. Prior to joining Capstone in 2014, he served as the Medical Director for a PACE (Program for All-Inclusive Care for the Elderly) program in Southwestern Pennsylvania. As a private practitioner for more than three decades, Dr. Brett specialized in internal medicine and geriatrics and served as medical director for several long-term care facilities and hospice organizations, in addition to PACE. His work with PACE led to his interest and eventual expertise in Medicare risk adjustment. He is a frequent presenter on topics including polypharmacy in the elderly and Medicare risk adjustment.

In the move to home-based care, clinician experience matters more than ever


A recent piece published in the Journal of the American Medical Informatics Association discussed the current administration’s efforts to address clinician burnout and improve usability of and satisfaction with healthcare technology. While the article stresses three important areas of focus such as improved health IT system designs, enhanced system configuration decisions, and increased end user training during health IT implementation, it misses the mark on additional challenge areas – particularly as it relates to two significant shifts in how care is delivered.

As more providers and payers make the transition away from offices and hospitals to living rooms, they are increasingly looking to embrace new value-driven approaches to patient care.

The first shift is the move to home-based models of care and the second is the transition to value over volume – both go hand-in-hand to some degree. As more providers and payers make the transition away from offices and hospitals to living rooms , they are increasingly looking to embrace new value-driven approaches to patient care. These new approaches include, but are not limited to, longer visits that prioritize a holistic understanding of the patient while focusing on relationship building – and expanding the type of care team members in the patients’ home.

These changes and others associated with the move to home-based care models mean physicians and care teams need to fundamentally shift their practice of medicine – and in a good way. Still, change is never easy – especially amid a pandemic.

Healthcare organizations looking to adopt at-home, value-driven care models while supporting their clinical staff through this transition should carefully consider the appropriate role technology can play in simplifying these changes. More so, these organizations would be well-served to consider lessons learned from the widespread adoption of healthcare technology over the last decade and move to reduce, not increase, the administrative burden for providers.

If the end goal of value-based care is driving improved outcomes and reducing costs over time, we must “begin at the beginning” – with the doctor and the patient at the point of care.

As part of the strategy to streamline adoption of home-based, value-driven care, healthcare organizations should ensure clinicians have the tools and support to make these efforts successful. If the end goal of value-based care is driving improved outcomes and reducing costs over time, we must “begin at the beginning” – with the doctor and the patient at the point of care. Organizations that are adding new workflows, data and administrative duties to doctors are missing the point and are setting themselves up for failure. As one of my close physician friends recently shared, if it’s not in the current electronic health record workflow, he doesn’t want to have anything to do with it. Doctors simply don’t have additional time and mindshare to offer up to mediocre technology – even if it supports improved patient outcomes.

With much of the healthcare industry focused on bringing at-home models of care to market in support of the transition to value-based care, building on what we have learned from the pandemic, clinician experience matters more than ever. We need to collectively look to adopt technologies and best practices that are provider approved and focused on workflow. Doing so will allow clinicians and care teams to focus on making personalized, holistic, at-home patient care a reality – while reducing the mental drain associated with paperwork and technological challenges.



Curation Health helps providers and health plans navigate and scale from fee-for-service to value-based care. Our advanced clinical decision support platform for value-based care drives more accurate risk adjustment and quality program performance by curating and delivering relevant, real-time insights to the clinician and care team. For more information, visit

Social Isolation And Loneliness Attributed To COVID-19

By Cori McMahon, Psy.D, NCCE, Vice President for Clinical Services, Tridiuumdepressed senior on side of bed

The challenges we have faced as a society during the COVID-19 pandemic are many, and some of them are yet to be fully evaluated for their potential impact. Often underestimated, social isolation and loneliness are serious public health risks that disproportionately affect the older adult population yet are currently impacting everyone, regardless of age. While “social isolation” and “loneliness” are two different concepts, they often overlap, Social isolation can be defined as the objective state of having few social relationships or infrequent contact with others, while loneliness is a subjective feeling of being isolated, which one can experience even in a crowded room or while among loved ones.

Studies around the world are measuring the psychological impact of COVID-19 on our kids and are finding, unanimously, that social isolation is having a negative impact on mood functioning, sleep, and overall behavior.

Considering the youngest members of our society, children and adolescents have experienced an upheaval of daily routines, academic expectations, and the essential interpersonal connection they are able to enjoy while with their peers in-person at school. Studies around the world are measuring the psychological impact of COVID-19 on our kids and are finding, unanimously, that social isolation is having a negative impact on mood functioning, sleep, and overall behavior. One online questionnaire that was administered in China to more than 3,600 children and adolescents revealed that approximately 22% of youth had scores indicative of clinical depression as compared to 13%—the estimated national prevalence. In another survey, over 8,000 junior and senior high school students completed the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder (GAD-7) scales. Results indicated the prevalence of depressive symptoms was 43.7%; anxiety symptoms was 31.3%; and both depressive and anxious symptoms combined was at 31.3%. (Wagner 2020)

depressed school girl on sofa

Multiple additional studies have resulted in similar findings, and a systematic review conducted by Loades et. al. summarized 83 different articles on the same topic (Loades 2020). Authors note concern that children and adolescents are probably more likely to experience high rates of depression and most likely to experience anxiety during and after the end of enforced isolation. The review shares both considerations for intervention and a call to action, explaining that strategies to prevent the development of mental health problems like these in youth should be an international priority.

With approximately 46 million Americans (14% of the population) over age 64, this group is at greater risk for both physical and psychological complications during this challenging time.

According to a report from the National Academics of Sciences, Engineering, and Medicine, in the US, approximately one-quarter of community-dwelling older adults are considered to be socially isolated and 43% of them report feeling lonely (National Academies Press). Stay-at-home orders and visitor restrictions during COVID-19 have only served to increase that number. With approximately 46 million Americans (14% of the population) over age 64, this group is at greater risk for both physical and psychological complications during this challenging time. Koma et. al. found one in four adults over 65 reporting anxiety or depression during most weeks since the onset of the pandemic, and increase from one in 10 older adults who reported anxiety or depression in 2018 (Koma 2020). Combining an increased likelihood for health issues such as cardiovascular disease, respiratory illness, or diabetes, which raise the risk of severe COVID-19 and the potential for isolation or cognitive decline, older adults are positioned to fare worse than the rest of the population. Further, an article in Public Health Nursing notes while adults over 75 comprise only 12% of the US population, they have some of the highest suicide rates, accounting for 18% of suicides annually. The authors explain that the pandemic has heightened the risk for “deaths of despair.” (Troutman 2020)

Intervening to decrease the impact of social isolation

While it may remain necessary to physically distance for some time to come, it is increasingly important to focus on social connection. Research has shown that depressive symptoms may be reduced by increasing social support and that the negative impact of physical distancing can be mediated by maintaining the structure, quality, and quantity of social networks. (Gong 2020) Knowing that loneliness is connected with mental health challenges in youth, it is important to help children and adolescents experience social rewards, to feel part of a group, and to know there are others to whom they can look for support. It is important for parents to look to strike a balance between concerns for too much screen time on social media with the benefits of social connectedness.

caregiver showing senior gentleman how to use tablet
Recommendations for mental and physical health in older individuals are focused similarly, in that strengthening social connectedness is key (Sepulveda-Loyola 2020). Whether one leverages technology to connect via video chat, internet apps or the telephone, it is essential to remain engaged. caregiver showing senior gentleman how to use tabletCaregivers also play a critical role in supporting the well-being of the older person. They can help reduce anxiety by engaging loved ones in adapted daily activities as is possible, by providing clear information and thinking about exposure to sensational media, and, if needed, by employing health education and counseling to focus on resiliency. Yes, we are, in theory, “all in this together,” however, it takes concerted effort to remain socially connected in this unprecedented time. Our health depends on it.



Gong, X, Ni, Z, Wu, B. The mediating roles of functional limitations and social support on the relationship between vision impairment and depressive symptoms in older adults. Cambridge University Press.

Koma, W, True, S, Fuglesten Biniek, J, Cubanski, J, Orgera, K, Garfield, R. One in Four Older Adults Report Anxiety or Depression Amid the COVID-19 Pandemic. Kaiser Family Foundation

Loades, M, Chatburn, E, Higson-Sweeney, N, Reynolds, S, Shafran, R, Brigden, A, Linney, C, McManus, M, Borwick, C, Crawley, E. J Am Acad Child Adolesc Psychiatry. 2020 Nov; 59(11): 1218–1239.e3. Published online 2020 Jun 3.

National Academies of Sciences, Engineering, and Medicine 2020. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: The National Academies Press.

Sepulveda-Loyola, W. J Nutr Health Aging. 2020 Sep 25 : 1–10.

Troutman-Jordan M, Kazemi DM. Public Health Nurs. 2020; ePub(ePub): ePub.

Wagner, K. New Findings About Children’s Mental Health During COVID-19. Psychiatric Times.

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