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Glossary

Everything about preventative care management is changing. At ChronicCareIQ, we want to help you stay up-to-date on the latest terminology, technology, and information that can help you grow your practice with confidence.

Chronic Care Management Glossary

Acute intrinsic kidney failure can result from direct trauma to the kidneys, such as physical impact or an accident. Other causes include toxin overload and ischemia, which is a lack of oxygen to the kidneys. Ischemia can be caused by severe bleeding, shock, obstruction of the renal blood vessel, and glomerulonephritis, a condition where the tiny blood vessels in your kidneys become inflamed. (healthline.com)

Insufficient blood flow to the kidneys can cause acute prerenal kidney failure. The kidneys can’t filter toxins from the blood without enough blood flow. This type of kidney failure can usually be cured once the cause of the decreased blood flow is determined. (healthline.com)

Arthritis isn’t a single disease; the term refers to joint pain or joint disease, and there are more than 100 types of arthritis and related conditions. People of all ages, races and sexes live with arthritis, and it is the leading cause of disability in the U.S. It’s most common among women, and although it’s not a disease of aging, some types of arthritis occur in older people more than younger people. (arthritis.org)

Asthma is a disease that inflames and narrows your airways and makes it hard to breathe. (webmd.com)

A healthy immune system is protective. It generates inflammation to clear infections and heal injuries. But in inflammatory arthritis, the immune system is overactive, attacking healthy tissue, including joints in the spine, hands and feet. In some people, inflammation becomes systemic, damaging the eyes, skin, heart and other organs. Many, but not all types of inflammatory arthritis are considered autoimmune diseases because the immune system loses the ability to distinguish self from not-self and attacks the body it’s supposed to protect. . (arthritis.org)

Blood pressure is the force of your blood pushing against the walls of your arteries. Each time your heart beats, it pumps blood into the arteries. Your blood pressure is highest when your heart beats, pumping the blood. This is called systolic pressure. When your heart is at rest, between beats, your blood pressure falls. This is called diastolic pressure. (medlineplus.gov)

Cardiology is a medical specialty and a branch of internal medicine concerned with disorders of the heart. It deals with the diagnosis and treatment of such conditions as congenital heart defects, coronary artery disease, electrophysiology, heart failure and valvular heart disease.

(mayoclinic.org)

Care coordination in the primary care practice involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. (ahrq.gov)

Comprehensive Care Plans help clients work with their Care Team to plan, document, and accomplish individualized care goals and healthier outcomes. (cdc.gov)

Care transitions occur when a patient moves from one health care provider or setting to another. (innovation.cms.gov)

Care management is a promising team-based, patient-centered approach “designed to assist patients and their support systems in managing medical conditions more effectively.” It also encompasses those care coordination activities needed to help manage chronic illness. (ahrq.gov)

Examples of CCM services include structured recording of patient health information, keeping comprehensive electronic care plans, managing care transitions and other care management services, and coordinating and sharing patient health information promptly within and outside the practice (cms.gov)

Chronic diseases are defined broadly as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both. Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the United States. (cdc.org)

This happens when there’s long-term damage to the kidneys due to intrinsic kidney disease. Intrinsic kidney disease develops from a direct trauma to the kidneys, such as severe bleeding or a lack of oxygen. (healthline.com)

CKD is a condition in which the kidneys are damaged and cannot filter blood as well as they should. Because of this, excess fluid and waste from blood remain in the body and may cause other health problems, such as heart disease and stroke. (healthline.com)

Chronic obstructive pulmonary disease, or COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis. COPD makes breathing difficult for the 16 million Americans who have this disease. (cdc.gov)

A long-term blockage of the urinary tract prevents urination. This causes pressure and eventual kidney damage. (healthline.com)

Chronic Prerenal Kidney Failure

When there isn’t enough blood flowing to your kidneys for an extended period of time, the kidneys begin to shrink and lose the ability to function. (healthline.com)

Comorbidity means more than one disease or condition is present in the same person at the same time. Conditions described as comorbidities are often chronic or long-term conditions. Other names to describe comorbid conditions are coexisting or co-occurring conditions and sometimes also “multimorbidity” or “multiple chronic conditions.” (cdc.org)

The act of following a medical regimen or schedule correctly and consistently, including taking medicines or following a diet. (cancer.org)

The Comprehensive Care Plan is a four-section written plan developed by the client’s medical provider, the Care Coordination Team and the client to help the client achieve his or her treatment goals. (cdc.org)

Manage doctor’s appointments, medications, medical history, and more through this freshly designed and user-friendly mobile app. (connectedcareapp.com)

Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. (ahrq.gov)

CMS CPT Codes 99490, 99491, 99487, 99489 & G0506

CPT Code 99490 reimburses time spent by clinical staff — under the direction of a physician or QHP — of care coordination for patients with two or more non-complex chronic conditions. Code 99490 covers 20 minutes of time for non-face-to-face care, per patient per month (PPPM).

CPT Code 99491 reimburses time spent directly by a physician or QHP to manage care for patients with two or more non-complex chronic conditions. Code 99491 covers 30 minutes of time PPPM, with a maximum monthly amount of 60 minutes.

CPT Code 99487 covers complex CCM, defined as patients with two or more chronic conditions who require “moderate or high complexity medical decision making,” as per CMS guidelines. Code 99487 reimburses 60 minutes of time spent by clinical staff under the direction of a physician or QHP.

CPT Code 99489 covers each additional 30 minutes of complex chronic care management PPPM under the direction of a physician or QHP of care coordination, to be reported after the initial 60 minutes allowed for by 99487.

CCM code G0506 covers comprehensive assessment and care planning for patients with two or more chronic conditions, as provided by a physician or QHP.

Healthcare dashboards are analytics software tools which empower healthcare professionals to make real-time, data-driven decisions, by compiling information from multiple sources into one view. (medicaladvantage.com)

In medicine, the term decompensation refers to the deterioration of a structure or system that was previously functioning. (heart-failure.net)

Diabetes is a chronic (long-lasting) health condition that affects how your body turns food into energy. Your body breaks down most of the food you eat into sugar (glucose) and releases it into your bloodstream.  (cdc.org)

Disease progression describes the natural history of disease, such as pain, or biomarker of drug response, such as blood pressure. The action of a drug, such as inhibiting an enzyme or activating a receptor, leads to a change in disease status over time. (ncbi.nlm.nih.gov)

Emphysema is a disease of the lungs. It occurs most often in people who smoke, but it also occurs in people who regularly breathe in irritants.

Emphysema destroys alveoli, which are air sacs in the lungs. The air sacs weaken and eventually break, which reduces the surface area of the lungs and the amount of oxygen that can reach the bloodstream. This makes it harder to breathe, especially when exercising. Emphysema also causes the lungs to lose their elasticity. (healthline.com)

E-visits allow patients to talk to their doctor using an online patient portal without going to the doctor’s office. Providers who can give you these services include: Doctors, Nurse practitioners, and Physician assistants. (medicare.gov)

Gastroenterology is the branch of medicine that focuses on the digestive tract and the gallbladder, liver, bile ducts, and pancreas.  Gastroenterologists are doctors who are trained to diagnose and treat problems in your gastrointestinal (GI) tract and liver. (webmd.com)

Blood sugar, or glucose, is the main sugar found in your blood. It comes from the food you eat, and is your body’s main source of energy. Your blood carries glucose to all of your body’s cells to use for energy. Diabetes is a disease in which your blood sugar levels are too high. (medlineplus.gov)

Metabolic or gouty arthritis — commonly known as gout — results from a buildup in joints of painful uric acid crystals. These are a byproduct of the breakdown of purines — substances normally found in human cells and many foods, especially red meat, organ meats, some seafoods and alcohol. Normally the body gets rid of excess uric acid, but when it doesn’t, it can accumulate in joints, causing sudden and intense bouts of pain, especially the big toe. . (arthritis.org)

Gross revenue is the amount of money a business brings in from sales in a given period. (businessnewsdaily.com)

Healthcare professionals maintain health in humans through the application of the principles and procedures of evidence-based medicine and caring. Health professionals study, diagnose, treat and prevent human illness, injury and other physical and mental impairments in accordance with the needs of the populations they serve. They advise on or apply preventive and curative measures, and promote health with the ultimate goal of meeting the health needs and expectations of individuals and populations, and improving population health outcomes. They also conduct research and improve or develop concepts, theories and operational methods to advance evidence-based health care. (ncbi.nlm.nih.gov)

A healthcare provider is a person or entity that provides medical care or treatment. Healthcare providers include doctors, nurse practitioners, midwives, radiologists, labs, hospitals, urgent care clinics, medical supply companies, and other professionals, facilities, and businesses that provide such services. (verywellhealth.com)

Hemolytic uremic syndrome (HUS) is a complex condition where an immune reaction, most commonly after a gastrointestinal tract infection, causes low red blood cell levels, low platelet levels, and kidney injury. (healthline.com)

Hepatology is an area of medicine that focuses on diseases of the liver as well as related conditions. A hepatologist is a specialized doctor involved in the diagnosis and treatment of hepatic diseases, which include issues that affect your liver or gallbladder. (healthline.com)

When patients leave a hospital after treatment, they go through a process called hospital discharge. A hospital will discharge a patient when the patient no longer needs to receive inpatient care and can go home or be discharged to another care setting. (hopkinsmedicine.org)

A bacterial, viral or fungal infection triggers infectious arthritis. It usually starts when an infection from another part of the body travels to a joint, usually the knee. Symptoms like swelling, pain and fever can be sudden and intense, but treatment with antibiotics or antifungals usually clears the infection pretty quickly. Most viral infections last a week or two and go away on their own. (arthritis.org)

An internist is a doctor of internal medicine. They’re doctors who specialize in the internal organs and systems of the body, but they are not limited to those areas. (webmd.com)

Interstitial lung disease is an umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs. The scarring causes stiffness in the lungs which makes it difficult to breathe and get oxygen to the bloodstream. Lung damage from ILDs is often irreversible and gets worse over time. (lung.org)

In medicine, a treatment, procedure, or other action taken to prevent or treat disease, or improve health in other ways. (cancer.gov)

Kidney cancer is cancer that begins in the kidneys. Your kidneys are two bean-shaped organs, each about the size of your fist. They’re located behind your abdominal organs, with one kidney on each side of your spine. (mayoclinic.org)

Lung cancer begins in the lungs and may spread to lymph nodes or other organs in the body, such as the brain. Cancer from other organs also may spread to the lungs. (cdc.gov)

Medical technology is the use of technology to develop solutions to health issues and to improve wellbeing.

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, or people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD) (medicare.gov)

Medication adherence usually refers to whether patients take their medications as prescribed (e.g., twice daily), as well as whether they continue to take a prescribed medication. (ahajournals.org)

Medication Management Services are a spectrum of patient-centered, pharmacist provided, collaborative services that focus on medication appropriateness, effectiveness, safety, and adherence with the goal of improving health outcomes. (jcpp.net)

Net revenue is the amount of money a business brings in from sales in a given period minus the expenses it incurred over the same period. (businessnewsdaily.com)

Osteoarthritis is by far the most common type of arthritis. It can damage almost any joint but mainly occurs in the hands, spine, hips and knees. OA was once considered a wear-and-tear disease in which cartilage — the protective layer on the ends of bones — wore down after years of use. But with further research, the thinking about OA has changed. Doctors now know that OA is a disease of the whole joint, not just cartilage. Bones in affected joints become weaker, the connective tissue that holds the joint together deteriorates and inflammation damages the joint lining. Contrary to decades of belief, inflammation plays a key role in OA, just as it does in most other types of arthritis. (arthritis.org)

Accordion Content

Patient care refers to the prevention, treatment, and management of illness and the preservation of physical and mental well-being through services offered by health professionals. (hhrguide.org)

Protected health information (PHI), also referred to as personal health information, is the demographic information, medical histories, test and laboratory results, mental health conditions, insurance information and other data that a healthcare professional collects to identify an individual and determine appropriate care. (techtarget.com)

Observation is a special service or status that allows physicians to place a patient in an acute care setting, within the hospital, for a limited amount of time to determine the need for inpatient admission. The patient will receive periodic monitoring by the hospital’s nursing staff while in observation. (martinhealth.org)

Peak flow measurement is a quick test to measure air flowing out of the lungs. The measurement is also called the peak expiratory flow rate (PEFR) or the peak expiratory flow (PEF). Peak flow measurement is mostly done by people who have asthma. Peak flow measurement can show the amount and rate of air that can be forcefully breathed out of the lungs. (hopkinsmedicine.org)

The overall approach to the assessment, management, and outcome measurement to address the expectations and needs prioritized as important by the patient and family. (pallipedia.org)

Pneumonia, an infection that makes the air sacs (alveoli) in your lungs inflamed and filled with pus.

Polycystic kidney disease (PKD) is an inherited kidney disorder. It causes fluid-filled cysts to form in the kidneys. PKD may impair kidney function and eventually cause kidney failure. (healthline.com)

PCP is an abbreviation used to refer to primary care physicians or primary care providers. This is the doctor, nurse practitioner, clinical nurse specialist, physician assistant, or even health care clinic that provides and coordinates your health care. (webmd.com)

A pulmonologist is a doctor who diagnoses and treats diseases of the respiratory system — the lungs and other organs that help you breathe.

Renal artery stenosis (RAS) is a condition in which the arteries that supply blood to the kidneys narrow. The renal arteries are responsible for carrying oxygen-rich blood to your kidneys, which in turn helps the kidneys rid your body of waste and excess fluid. Over time, RAS can lead to high blood pressure, edema, and kidney damage. (healthline.com)

Skilled care refers to skilled nursing or rehabilitation services, provided by licensed health professionals like nurses and physical therapists, ordered by a doctor.  (cms.gov)

Subacute care provides a specialized level of care to medically fragile patients, though often with a longer length of stay than acute care. Many patients with acute illness or injury require comprehensive care that includes frequent assessments and procedures to manage their condition. People with pulmonary disease, cardiac disease, cancer, and conditions requiring IV therapy or tube feedings may need subacute care after a hospital stay.  Subacute care can include dialysis, chemotherapy, ventilation care, complex wound care, and other inpatient medical and nursing services. (bellavistahealth.com)

Telemedicine involves the use of electronic communications and software to provide clinical services to patients without an in-person visit. Telemedicine technology is frequently used for follow-up visits, management of chronic conditions, medication management, specialist consultation and a host of other clinical services that can be provided remotely via secure video and audio connections. (chironhealth.com)

Telehealth — sometimes called telemedicine — lets your health care provider provide care for you without an in-person office visit. Telehealth is done primarily online with internet access on your computer, tablet, or smartphone. (telehealth.hhs.gov)

Care involved when a patient/client leaves one care setting (i.e. hospital, nursing home, assisted living facility, SNF, primary care physician, home health, or specialist) and moves to another. (nacns.org)

Transitional care management ensures patients who have a high-risk medical condition will receive the care they need immediately after discharge from a hospital or other facility. Learn more about how to get paid for this service. (aafp.org)

Transitional Care Management Glossary

Assisted living communities are personal care homes which choose to serve 25 residents or more and which provide assisted living care which consists of the provision of personal services, the administration of medications by a certified medication aide and the provision of assisted self-preservation. (Personal services include but are not limited to individual assistance with and supervision of self-administered medications and essential activities or daily living such as eating, bathing, grooming, dressing, and toileting.) (dch.georgia.gov)

Physician (any specialty)

Clinical nurse specialist (CNS)

Nurse practitioner (NP)

Physician assistant (PA)

Certified nurse midwife (aafp.org)

Cardiology is a medical specialty and a branch of internal medicine concerned with disorders of the heart. It deals with the diagnosis and treatment of such conditions as congenital heart defects, coronary artery disease, electrophysiology, heart failure and valvular heart disease.

(mayoclinic.org)

Care coordination in the primary care practice involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. (ahrq.gov)

Comprehensive Care Plans help clients work with their Care Team to plan, document, and accomplish individualized care goals and healthier outcomes. (cdc.gov)

Care transitions occur when a patient moves from one health care provider or setting to another. (innovation.cms.gov)

Care management is a promising team-based, patient-centered approach “designed to assist patients and their support systems in managing medical conditions more effectively.” It also encompasses those care coordination activities needed to help manage chronic illness. (ahrq.gov)

Care Team means the coordinated team of staff and healthcare professionals organized around a particular patient and family, whose common goal is the delivery of safe and effective care through patient and family engagement. (lawinsider.com)

A chronic condition develops and worsens over an extended period of time. (medlineplus.gov)

Community mental health care includes provision of crisis support, protected housing, and sheltered employment in addition to management of disorders to address the multiple needs of individuals.(sciencedirect.com)

The act of following a medical regimen or schedule correctly and consistently, including taking medicines or following a diet. (cancer.org)

Comorbidity means more than one disease or condition is present in the same person at the same time. Conditions described as comorbidities are often chronic or long-term conditions. Other names to describe comorbid conditions are coexisting or co-occurring conditions and sometimes also “multimorbidity” or “multiple chronic conditions.” (cdc.org)

The Comprehensive Care Plan is a four-section written plan developed by the client’s medical provider, the Care Coordination Team and the client to help the client achieve his or her treatment goals. (cdc.org)

Manage doctor’s appointments, medications, medical history, and more through this freshly designed and user-friendly mobile app. (connectedcareapp.com)

Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. (ahrq.gov)

The two CPT codes used to report TCM services are:

CPT code 99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge

CPT code 99496 – high medical complexity requiring a face-to-face visit within seven days of discharge (aafp.org)

Disease progression describes the natural history of disease, such as pain, or biomarker of drug response, such as blood pressure. The action of a drug, such as inhibiting an enzyme or activating a receptor, leads to a change in disease status over time. (ncbi.nlm.nih.gov)

Healthcare professionals maintain health in humans through the application of the principles and procedures of evidence-based medicine and caring. Health professionals study, diagnose, treat and prevent human illness, injury and other physical and mental impairments in accordance with the needs of the populations they serve. They advise on or apply preventive and curative measures, and promote health with the ultimate goal of meeting the health needs and expectations of individuals and populations, and improving population health outcomes. They also conduct research and improve or develop concepts, theories and operational methods to advance evidence-based health care. (ncbi.nlm.nih.gov)

A healthcare provider is a person or entity that provides medical care or treatment. Healthcare providers include doctors, nurse practitioners, midwives, radiologists, labs, hospitals, urgent care clinics, medical supply companies, and other professionals, facilities, and businesses that provide such services. (verywellhealth.com)

Health Crisis means any crisis or serious incident arising from a threat of human, animal, plant, food or environment origin, having a health dimension and which requires urgent action by authorities. (lawinsider.com)

When patients leave a hospital after treatment, they go through a process called hospital discharge. A hospital will discharge a patient when the patient no longer needs to receive inpatient care and can go home or be discharged to another care setting. (hopkinsmedicine.org)

Inpatient care is medical treatment administered to a patient whose condition requires treatment in a hospital or other health care facility, and the patient is formally admitted to the facility by a doctor. (medicareresources.org)

An internist is a doctor of internal medicine. They’re doctors who specialize in the internal organs and systems of the body, but they are not limited to those areas. (webmd.com)

IRFs are free standing rehabilitation hospitals and rehabilitation units in acute care hospitals.  They provide an intensive rehabilitation program and patients who are admitted must be able to tolerate three hours of intense rehabilitation services per day. 

An internist is a doctor of internal medicine. They’re doctors who specialize in the internal organs and systems of the body, but they are not limited to those areas. (webmd.com)

In medicine, a treatment, procedure, or other action taken to prevent or treat disease, or improve health in other ways. (cancer.gov)

Long‑term care hospitals (LTCHs) are certified as acute‑care hospitals, but LTCHs focus on patients who, on average, stay more than 25 days. Many of the patients in LTCHs are transferred there from an intensive or critical care unit. (medicare.gov)

Medical technology is the use of technology to develop solutions to health issues and to improve wellbeing.

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, or people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD) (medicare.gov)

Medication adherence usually refers to whether patients take their medications as prescribed (e.g., twice daily), as well as whether they continue to take a prescribed medication. (ahajournals.org)

Medication Management Services are a spectrum of patient-centered, pharmacist provided, collaborative services that focus on medication appropriateness, effectiveness, safety, and adherence with the goal of improving health outcomes. (jcpp.net)

A range of services provided to individual patients to optimize therapeutic outcomes (help patients get the most benefit from their medications) and detect and prevent costly medication problems. (accp.com)

A nursing home is a place for people who don’t need to be in a hospital but can’t be cared for at home. Most nursing homes have nursing aides and skilled nurses on hand 24 hours a day. (medlineplus.gov)

Patients receiving outpatient care don’t need to spend a night in a hospital. They’re free to leave the doctor’s office, outpatient clinic or hospital once the procedure is over. (pbmchealth.org)

Protected health information (PHI), also referred to as personal health information, is the demographic information, medical histories, test and laboratory results, mental health conditions, insurance information and other data that a healthcare professional collects to identify an individual and determine appropriate care. (techtarget.com)

Partial hospitalization provides a structured program of outpatient psychiatric services as an alternative to inpatient psychiatric care. It’s more intense than care you get in a doctor’s or therapist’s office. You get this treatment during the day, and you don’t have to stay overnight. Medicare helps cover partial hospitalization services you get through a hospital outpatient department or community mental health center. (medicare.gov)

Accordion Content

Patient care refers to the prevention, treatment, and management of illness and the preservation of physical and mental well-being through services offered by health professionals. (hhrguide.org)

Observation is a special service or status that allows physicians to place a patient in an acute care setting, within the hospital, for a limited amount of time to determine the need for inpatient admission. The patient will receive periodic monitoring by the hospital’s nursing staff while in observation. (martinhealth.org)

The overall approach to the assessment, management, and outcome measurement to address the expectations and needs prioritized as important by the patient and family. (pallipedia.org)

While post-acute care provides continued medical treatment after a hospital stay, it maintains an emphasis on recuperation, rehabilitation, and symptom management. Patients in recovery from cardiac or pulmonary disease, stroke or neurological disorders, or orthopedic surgery often require rehabilitative therapies to help bridge the gap between hospital and home. The goal of post-acute rehabilitation is to maximize patient wellness and independence so they can get back to the business of living their best lives. Post-acute care services range from intensive short-term rehab to longer-term restorative care. Some patients will achieve full recovery, while others learn to manage the symptoms of a chronic illness. (bellavistahealth.com)

A primary care provider is considered your main medical provider. Your PCP is responsible for dealing with the majority of your routine healthcare issues, and for coordinating care with specialists you may need to see. (verywellhealth.com)

Is primarily engaged in providing, by or under the supervision of a Doctor of Medicine or Osteopathy, psychiatric services for the diagnosis and treatment of mentally ill persons. (cms.gov)

Skilled care refers to skilled nursing or rehabilitation services, provided by licensed health professionals like nurses and physical therapists, ordered by a doctor.  (cms.gov)

Subacute care provides a specialized level of care to medically fragile patients, though often with a longer length of stay than acute care. Many patients with acute illness or injury require comprehensive care that includes frequent assessments and procedures to manage their condition. People with pulmonary disease, cardiac disease, cancer, and conditions requiring IV therapy or tube feedings may need subacute care after a hospital stay.  Subacute care can include dialysis, chemotherapy, ventilation care, complex wound care, and other inpatient medical and nursing services. (bellavistahealth.com)

Telemedicine involves the use of electronic communications and software to provide clinical services to patients without an in-person visit. Telemedicine technology is frequently used for follow-up visits, management of chronic conditions, medication management, specialist consultation and a host of other clinical services that can be provided remotely via secure video and audio connections. (chironhealth.com)

Telehealth — sometimes called telemedicine — lets your health care provider provide care for you without an in-person office visit. Telehealth is done primarily online with internet access on your computer, tablet, or smartphone. (telehealth.hhs.gov)

Transitional Care Management

  • Contact the beneficiary or caregiver within two business days following a discharge. The contact may be via telephone, email, or a face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful.
  • Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision making involved. The face-to-face visit is part of the TCM service and should not be reported separately.
  • Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit.
  • Obtain and review discharge information.
  • Review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments.
  • Educate the beneficiary, family member, caregiver, and/or guardian.
  • Establish or re-establish referrals with community providers and services, if necessary.
  • Assist in scheduling follow-up visits with providers and services, if necessary.
  • Discharge from any of the following:
    • Inpatient acute care hospital
    • Long-term acute care hospital
    • Skilled nursing facility/nursing facility
    • Inpatient rehabilitation facility
    • Hospital observation status or partial hospitalization

Care involved when a patient/client leaves one care setting (i.e. hospital, nursing home, assisted living facility, SNF, primary care physician, home health, or specialist) and moves to another. (nacns.org)

Transitional care management ensures patients who have a high-risk medical condition will receive the care they need immediately after discharge from a hospital or other facility. Learn more about how to get paid for this service. (aafp.org)

Remote Patient Monitoring Glossary

Acute intrinsic kidney failure can result from direct trauma to the kidneys, such as physical impact or an accident. Other causes include toxin overload and ischemia, which is a lack of oxygen to the kidneys. Ischemia can be caused by severe bleeding, shock, obstruction of the renal blood vessel, and glomerulonephritis, a condition where the tiny blood vessels in your kidneys become inflamed. (healthline.com)

Insufficient blood flow to the kidneys can cause acute prerenal kidney failure. The kidneys can’t filter toxins from the blood without enough blood flow. This type of kidney failure can usually be cured once the cause of the decreased blood flow is determined. (healthline.com)

Arthritis isn’t a single disease; the term refers to joint pain or joint disease, and there are more than 100 types of arthritis and related conditions. People of all ages, races and sexes live with arthritis, and it is the leading cause of disability in the U.S. It’s most common among women, and although it’s not a disease of aging, some types of arthritis occur in older people more than younger people. (arthritis.org)

Asthma is a disease that inflames and narrows your airways and makes it hard to breathe. (webmd.com)

A healthy immune system is protective. It generates inflammation to clear infections and heal injuries. But in inflammatory arthritis, the immune system is overactive, attacking healthy tissue, including joints in the spine, hands and feet. In some people, inflammation becomes systemic, damaging the eyes, skin, heart and other organs. Many, but not all types of inflammatory arthritis are considered autoimmune diseases because the immune system loses the ability to distinguish self from not-self and attacks the body it’s supposed to protect. . (arthritis.org)

Blood pressure is the force of your blood pushing against the walls of your arteries. Each time your heart beats, it pumps blood into the arteries. Your blood pressure is highest when your heart beats, pumping the blood. This is called systolic pressure. When your heart is at rest, between beats, your blood pressure falls. This is called diastolic pressure. (medlineplus.gov)

Cardiology is a medical specialty and a branch of internal medicine concerned with disorders of the heart. It deals with the diagnosis and treatment of such conditions as congenital heart defects, coronary artery disease, electrophysiology, heart failure and valvular heart disease.

(mayoclinic.org)

Care coordination in the primary care practice involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. (ahrq.gov)

Comprehensive Care Plans help clients work with their Care Team to plan, document, and accomplish individualized care goals and healthier outcomes. (cdc.gov)

Care transitions occur when a patient moves from one health care provider or setting to another. (innovation.cms.gov)

Care management is a promising team-based, patient-centered approach “designed to assist patients and their support systems in managing medical conditions more effectively.” It also encompasses those care coordination activities needed to help manage chronic illness. (ahrq.gov)

Examples of CCM services include structured recording of patient health information, keeping comprehensive electronic care plans, managing care transitions and other care management services, and coordinating and sharing patient health information promptly within and outside the practice (cms.gov)

Chronic diseases are defined broadly as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both. Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the United States. (cdc.org)

This happens when there’s long-term damage to the kidneys due to intrinsic kidney disease. Intrinsic kidney disease develops from a direct trauma to the kidneys, such as severe bleeding or a lack of oxygen. (healthline.com)

CKD is a condition in which the kidneys are damaged and cannot filter blood as well as they should. Because of this, excess fluid and waste from blood remain in the body and may cause other health problems, such as heart disease and stroke. (healthline.com)

Chronic obstructive pulmonary disease, or COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis. COPD makes breathing difficult for the 16 million Americans who have this disease. (cdc.gov)

A long-term blockage of the urinary tract prevents urination. This causes pressure and eventual kidney damage. (healthline.com)

Chronic Prerenal Kidney Failure

When there isn’t enough blood flowing to your kidneys for an extended period of time, the kidneys begin to shrink and lose the ability to function. (healthline.com)

Comorbidity means more than one disease or condition is present in the same person at the same time. Conditions described as comorbidities are often chronic or long-term conditions. Other names to describe comorbid conditions are coexisting or co-occurring conditions and sometimes also “multimorbidity” or “multiple chronic conditions.” (cdc.org)

The act of following a medical regimen or schedule correctly and consistently, including taking medicines or following a diet. (cancer.org)

The Comprehensive Care Plan is a four-section written plan developed by the client’s medical provider, the Care Coordination Team and the client to help the client achieve his or her treatment goals. (cdc.org)

Manage doctor’s appointments, medications, medical history, and more through this freshly designed and user-friendly mobile app. (connectedcareapp.com)

Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. (ahrq.gov)

CMS CPT Codes 99490, 99491, 99487, 99489 & G0506

CPT Code 99490 reimburses time spent by clinical staff — under the direction of a physician or QHP — of care coordination for patients with two or more non-complex chronic conditions. Code 99490 covers 20 minutes of time for non-face-to-face care, per patient per month (PPPM).

CPT Code 99491 reimburses time spent directly by a physician or QHP to manage care for patients with two or more non-complex chronic conditions. Code 99491 covers 30 minutes of time PPPM, with a maximum monthly amount of 60 minutes.

CPT Code 99487 covers complex CCM, defined as patients with two or more chronic conditions who require “moderate or high complexity medical decision making,” as per CMS guidelines. Code 99487 reimburses 60 minutes of time spent by clinical staff under the direction of a physician or QHP.

CPT Code 99489 covers each additional 30 minutes of complex chronic care management PPPM under the direction of a physician or QHP of care coordination, to be reported after the initial 60 minutes allowed for by 99487.

CCM code G0506 covers comprehensive assessment and care planning for patients with two or more chronic conditions, as provided by a physician or QHP.

Healthcare dashboards are analytics software tools which empower healthcare professionals to make real-time, data-driven decisions, by compiling information from multiple sources into one view. (medicaladvantage.com)

In medicine, the term decompensation refers to the deterioration of a structure or system that was previously functioning. (heart-failure.net)

Diabetes is a chronic (long-lasting) health condition that affects how your body turns food into energy. Your body breaks down most of the food you eat into sugar (glucose) and releases it into your bloodstream.  (cdc.org)

Disease progression describes the natural history of disease, such as pain, or biomarker of drug response, such as blood pressure. The action of a drug, such as inhibiting an enzyme or activating a receptor, leads to a change in disease status over time. (ncbi.nlm.nih.gov)

Emphysema is a disease of the lungs. It occurs most often in people who smoke, but it also occurs in people who regularly breathe in irritants.

Emphysema destroys alveoli, which are air sacs in the lungs. The air sacs weaken and eventually break, which reduces the surface area of the lungs and the amount of oxygen that can reach the bloodstream. This makes it harder to breathe, especially when exercising. Emphysema also causes the lungs to lose their elasticity. (healthline.com)

E-visits allow patients to talk to their doctor using an online patient portal without going to the doctor’s office. Providers who can give you these services include: Doctors, Nurse practitioners, and Physician assistants. (medicare.gov)

Gastroenterology is the branch of medicine that focuses on the digestive tract and the gallbladder, liver, bile ducts, and pancreas.  Gastroenterologists are doctors who are trained to diagnose and treat problems in your gastrointestinal (GI) tract and liver. (webmd.com)

Blood sugar, or glucose, is the main sugar found in your blood. It comes from the food you eat, and is your body’s main source of energy. Your blood carries glucose to all of your body’s cells to use for energy. Diabetes is a disease in which your blood sugar levels are too high. (medlineplus.gov)

Metabolic or gouty arthritis — commonly known as gout — results from a buildup in joints of painful uric acid crystals. These are a byproduct of the breakdown of purines — substances normally found in human cells and many foods, especially red meat, organ meats, some seafoods and alcohol. Normally the body gets rid of excess uric acid, but when it doesn’t, it can accumulate in joints, causing sudden and intense bouts of pain, especially the big toe. . (arthritis.org)

Gross revenue is the amount of money a business brings in from sales in a given period. (businessnewsdaily.com)

Healthcare professionals maintain health in humans through the application of the principles and procedures of evidence-based medicine and caring. Health professionals study, diagnose, treat and prevent human illness, injury and other physical and mental impairments in accordance with the needs of the populations they serve. They advise on or apply preventive and curative measures, and promote health with the ultimate goal of meeting the health needs and expectations of individuals and populations, and improving population health outcomes. They also conduct research and improve or develop concepts, theories and operational methods to advance evidence-based health care. (ncbi.nlm.nih.gov)

A healthcare provider is a person or entity that provides medical care or treatment. Healthcare providers include doctors, nurse practitioners, midwives, radiologists, labs, hospitals, urgent care clinics, medical supply companies, and other professionals, facilities, and businesses that provide such services. (verywellhealth.com)

Hemolytic uremic syndrome (HUS) is a complex condition where an immune reaction, most commonly after a gastrointestinal tract infection, causes low red blood cell levels, low platelet levels, and kidney injury. (healthline.com)

Hepatology is an area of medicine that focuses on diseases of the liver as well as related conditions. A hepatologist is a specialized doctor involved in the diagnosis and treatment of hepatic diseases, which include issues that affect your liver or gallbladder. (healthline.com)

When patients leave a hospital after treatment, they go through a process called hospital discharge. A hospital will discharge a patient when the patient no longer needs to receive inpatient care and can go home or be discharged to another care setting. (hopkinsmedicine.org)

A bacterial, viral or fungal infection triggers infectious arthritis. It usually starts when an infection from another part of the body travels to a joint, usually the knee. Symptoms like swelling, pain and fever can be sudden and intense, but treatment with antibiotics or antifungals usually clears the infection pretty quickly. Most viral infections last a week or two and go away on their own. (arthritis.org)

An internist is a doctor of internal medicine. They’re doctors who specialize in the internal organs and systems of the body, but they are not limited to those areas. (webmd.com)

Interstitial lung disease is an umbrella term used for a large group of diseases that cause scarring (fibrosis) of the lungs. The scarring causes stiffness in the lungs which makes it difficult to breathe and get oxygen to the bloodstream. Lung damage from ILDs is often irreversible and gets worse over time. (lung.org)

In medicine, a treatment, procedure, or other action taken to prevent or treat disease, or improve health in other ways. (cancer.gov)

Kidney cancer is cancer that begins in the kidneys. Your kidneys are two bean-shaped organs, each about the size of your fist. They’re located behind your abdominal organs, with one kidney on each side of your spine. (mayoclinic.org)

Lung cancer begins in the lungs and may spread to lymph nodes or other organs in the body, such as the brain. Cancer from other organs also may spread to the lungs. (cdc.gov)

Medical technology is the use of technology to develop solutions to health issues and to improve wellbeing.

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, or people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD) (medicare.gov)

Medication adherence usually refers to whether patients take their medications as prescribed (e.g., twice daily), as well as whether they continue to take a prescribed medication. (ahajournals.org)

Medication Management Services are a spectrum of patient-centered, pharmacist provided, collaborative services that focus on medication appropriateness, effectiveness, safety, and adherence with the goal of improving health outcomes. (jcpp.net)

Net revenue is the amount of money a business brings in from sales in a given period minus the expenses it incurred over the same period. (businessnewsdaily.com)

Osteoarthritis is by far the most common type of arthritis. It can damage almost any joint but mainly occurs in the hands, spine, hips and knees. OA was once considered a wear-and-tear disease in which cartilage — the protective layer on the ends of bones — wore down after years of use. But with further research, the thinking about OA has changed. Doctors now know that OA is a disease of the whole joint, not just cartilage. Bones in affected joints become weaker, the connective tissue that holds the joint together deteriorates and inflammation damages the joint lining. Contrary to decades of belief, inflammation plays a key role in OA, just as it does in most other types of arthritis. (arthritis.org)

Accordion Content

Patient care refers to the prevention, treatment, and management of illness and the preservation of physical and mental well-being through services offered by health professionals. (hhrguide.org)

Protected health information (PHI), also referred to as personal health information, is the demographic information, medical histories, test and laboratory results, mental health conditions, insurance information and other data that a healthcare professional collects to identify an individual and determine appropriate care. (techtarget.com)

Observation is a special service or status that allows physicians to place a patient in an acute care setting, within the hospital, for a limited amount of time to determine the need for inpatient admission. The patient will receive periodic monitoring by the hospital’s nursing staff while in observation. (martinhealth.org)

Peak flow measurement is a quick test to measure air flowing out of the lungs. The measurement is also called the peak expiratory flow rate (PEFR) or the peak expiratory flow (PEF). Peak flow measurement is mostly done by people who have asthma. Peak flow measurement can show the amount and rate of air that can be forcefully breathed out of the lungs. (hopkinsmedicine.org)

The overall approach to the assessment, management, and outcome measurement to address the expectations and needs prioritized as important by the patient and family. (pallipedia.org)

Pneumonia, an infection that makes the air sacs (alveoli) in your lungs inflamed and filled with pus.

Polycystic kidney disease (PKD) is an inherited kidney disorder. It causes fluid-filled cysts to form in the kidneys. PKD may impair kidney function and eventually cause kidney failure. (healthline.com)

PCP is an abbreviation used to refer to primary care physicians or primary care providers. This is the doctor, nurse practitioner, clinical nurse specialist, physician assistant, or even health care clinic that provides and coordinates your health care. (webmd.com)

A pulmonologist is a doctor who diagnoses and treats diseases of the respiratory system — the lungs and other organs that help you breathe.

Renal artery stenosis (RAS) is a condition in which the arteries that supply blood to the kidneys narrow. The renal arteries are responsible for carrying oxygen-rich blood to your kidneys, which in turn helps the kidneys rid your body of waste and excess fluid. Over time, RAS can lead to high blood pressure, edema, and kidney damage. (healthline.com)

Skilled care refers to skilled nursing or rehabilitation services, provided by licensed health professionals like nurses and physical therapists, ordered by a doctor.  (cms.gov)

Subacute care provides a specialized level of care to medically fragile patients, though often with a longer length of stay than acute care. Many patients with acute illness or injury require comprehensive care that includes frequent assessments and procedures to manage their condition. People with pulmonary disease, cardiac disease, cancer, and conditions requiring IV therapy or tube feedings may need subacute care after a hospital stay.  Subacute care can include dialysis, chemotherapy, ventilation care, complex wound care, and other inpatient medical and nursing services. (bellavistahealth.com)

Telemedicine involves the use of electronic communications and software to provide clinical services to patients without an in-person visit. Telemedicine technology is frequently used for follow-up visits, management of chronic conditions, medication management, specialist consultation and a host of other clinical services that can be provided remotely via secure video and audio connections. (chironhealth.com)

Telehealth — sometimes called telemedicine — lets your health care provider provide care for you without an in-person office visit. Telehealth is done primarily online with internet access on your computer, tablet, or smartphone. (telehealth.hhs.gov)

Care involved when a patient/client leaves one care setting (i.e. hospital, nursing home, assisted living facility, SNF, primary care physician, home health, or specialist) and moves to another. (nacns.org)

Transitional care management ensures patients who have a high-risk medical condition will receive the care they need immediately after discharge from a hospital or other facility. Learn more about how to get paid for this service. (aafp.org)

Principal Care Management Glossary

The American Academy of Family Physicians is the national association of family doctors. It is one of the largest national medical organizations, with 127,600 members in 50 states, D.C., Puerto Rico, the Virgin Islands, and Guam, as well as internationally. (aafp.org)

Purposes of the AAFP include:

  • Providing responsible advocacy for and education of patients and the public in all health-related matters
  • Preserving and promoting quality cost-effective health care
  • Promoting the science and art of family medicine and ensuring an optimal supply of well-trained family physicians
  • Promoting and maintaining high standards among physicians who practice family medicine
  • Preserving the right of family physicians to engage in medical and surgical procedures for which they are qualified by training and experience
  • Providing advocacy, representation, and leadership for the specialty of family medicine
  • Maintaining and providing an organization with high standards to fulfill the above purposes and to represent the needs of its members

(aafp.org)

  • Patient-focused care
    • Quality of care with improved outcomes
  • Reduces costs
  • Provides compensation for services previously done at no cost
    • Opportunity for monthly billing per beneficiary

(ngsmedicare.com)

Blood pressure is the force of your blood pushing against the walls of your arteries. Each time your heart beats, it pumps blood into the arteries. Your blood pressure is highest when your heart beats, pumping the blood. This is called systolic pressure. When your heart is at rest, between beats, your blood pressure falls. This is called diastolic pressure. (medlineplus.gov)

Care coordination in the primary care practice involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. (ahrq.gov)

Comprehensive Care Plans help clients work with their Care Team to plan, document, and accomplish individualized care goals and healthier outcomes. (cdc.gov)

Care transitions occur when a patient moves from one health care provider or setting to another. (innovation.cms.gov)

Care management is a promising team-based, patient-centered approach “designed to assist patients and their support systems in managing medical conditions more effectively.” It also encompasses those care coordination activities needed to help manage chronic illness. (ahrq.gov)

Chronic diseases are defined broadly as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both. Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the United States. (cdc.org)

Comorbidity means more than one disease or condition is present in the same person at the same time. Conditions described as comorbidities are often chronic or long-term conditions. Other names to describe comorbid conditions are coexisting or co-occurring conditions and sometimes also “multimorbidity” or “multiple chronic conditions.” (cdc.org)

The act of following a medical regimen or schedule correctly and consistently, including taking medicines or following a diet. (cancer.org)

The Comprehensive Care Plan is a four-section written plan developed by the client’s medical provider, the Care Coordination Team and the client to help the client achieve his or her treatment goals. (cdc.org)

Manage doctor’s appointments, medications, medical history, and more through this freshly designed and user-friendly mobile app. (connectedcareapp.com)

Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. (ahrq.gov)

G2064- Comprehensive care management services

G2065- Comprehensive care management for a single high-risk disease service

 (thoroughcare.net)

Healthcare dashboards are analytics software tools which empower healthcare professionals to make real-time, data-driven decisions, by compiling information from multiple sources into one view. (medicaladvantage.com)

E-visits allow you to talk to your doctor using an online patient portal without going to the doctor’s office. Providers who can give you these services include: Doctors, Nurse practitioners, and Physician assistants. (medicare.gov)

Gross revenue is the amount of money a business brings in from sales in a given period. (businessnewsdaily.com)

Healthcare professionals maintain health in humans through the application of the principles and procedures of evidence-based medicine and caring. Health professionals study, diagnose, treat and prevent human illness, injury and other physical and mental impairments in accordance with the needs of the populations they serve. They advise on or apply preventive and curative measures, and promote health with the ultimate goal of meeting the health needs and expectations of individuals and populations, and improving population health outcomes. They also conduct research and improve or develop concepts, theories and operational methods to advance evidence-based health care. (ncbi.nlm.nih.gov)

  • Physicians
  • Certain nonphysician practitioners
  • Physician assistants
  • Clinical nurse specialist
  • Nurse practitioners
  • Certified nurse midwives
  • Rural Health Centers
  • Federally Qualified Health Center
  • Hospitals
  • Critical Access Hospitals

(ngsmedicare.com)

A healthcare provider is a person or entity that provides medical care or treatment. Healthcare providers include doctors, nurse practitioners, midwives, radiologists, labs, hospitals, urgent care clinics, medical supply companies, and other professionals, facilities, and businesses that provide such services. (verywellhealth.com)

More likely than others to get a particular disease, condition, or injury high-risk patients in the high-risk group. (cancer.gov)

When patients leave a hospital after treatment, they go through a process called hospital discharge. A hospital will discharge a patient when the patient no longer needs to receive inpatient care and can go home or be discharged to another care setting. (hopkinsmedicine.org)

An internist is a doctor of internal medicine. They’re doctors who specialize in the internal organs and systems of the body, but they are not limited to those areas. (webmd.com)

In medicine, a treatment, procedure, or other action taken to prevent or treat disease, or improve health in other ways. (cancer.gov)

Medical technology is the use of technology to develop solutions to health issues and to improve wellbeing.

To participate in Medicaid, federal law requires states to cover certain groups of individuals. Low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI) are examples of mandatory eligibility groups (PDF, 177.87 KB). States have additional options for coverage and may choose to cover other groups, such as individuals receiving home and community-based services and children in foster care who are not otherwise eligible. (Medicaid.gov)

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, or people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD) (medicare.gov)

Medication adherence usually refers to whether patients take their medications as prescribed (e.g., twice daily), as well as whether they continue to take a prescribed medication. (ahajournals.org)

Medication Management Services are a spectrum of patient-centered, pharmacist provided, collaborative services that focus on medication appropriateness, effectiveness, safety, and adherence with the goal of improving health outcomes. (jcpp.net)

In medicine, to regularly watch and check a person or condition to see if there is any change. Also refers to a device that records and/or displays patient data, such as for an electrocardiogram (EKG). (cancer.gov)

Net revenue is the amount of money a business brings in from sales in a given period minus the expenses it incurred over the same period. (businessnewsdaily.com)

Accordion Content

Patient care refers to the prevention, treatment, and management of illness and the preservation of physical and mental well-being through services offered by health professionals. (hhrguide.org)

Protected health information (PHI), also referred to as personal health information, is the demographic information, medical histories, test and laboratory results, mental health conditions, insurance information and other data that a healthcare professional collects to identify an individual and determine appropriate care. (techtarget.com)

The overall approach to the assessment, management, and outcome measurement to address the expectations and needs prioritized as important by the patient and family. (pallipedia.org)

A primary care provider (PCP) is a health care practitioner who sees people that have common medical problems. This person is most often a doctor. However, a PCP may be a physician assistant or a nurse practitioner. (medline.gov)

PCP is an abbreviation used to refer to primary care physicians or primary care providers. This is the doctor, nurse practitioner, clinical nurse specialist, physician assistant, or even health care clinic that provides and coordinates your health care. (webmd.com)

The service is intended to provide additional care to patients with a single chronic condition or allowing a provider to treat a patient with multiple chronic conditions by focusing care solely on one of those chronic conditions. (thoroughcare.net)

Healthcare reimbursement describes the payment that your hospital, healthcare provider, diagnostic facility, or other healthcare providers receive for giving you a medical service. (verywellhealth.com)

A primary care provider is considered your main medical provider. Your PCP is responsible for dealing with the majority of your routine healthcare issues, and for coordinating care with specialists you may need to see. (verywellhealth.com)

Skilled care refers to skilled nursing or rehabilitation services, provided by licensed health professionals like nurses and physical therapists, ordered by a doctor.  (cms.gov)

Subacute care provides a specialized level of care to medically fragile patients, though often with a longer length of stay than acute care. Many patients with acute illness or injury require comprehensive care that includes frequent assessments and procedures to manage their condition. People with pulmonary disease, cardiac disease, cancer, and conditions requiring IV therapy or tube feedings may need subacute care after a hospital stay.  Subacute care can include dialysis, chemotherapy, ventilation care, complex wound care, and other inpatient medical and nursing services. (bellavistahealth.com)

Telemedicine involves the use of electronic communications and software to provide clinical services to patients without an in-person visit. Telemedicine technology is frequently used for follow-up visits, management of chronic conditions, medication management, specialist consultation and a host of other clinical services that can be provided remotely via secure video and audio connections. (chironhealth.com)

Telehealth — sometimes called telemedicine — lets your health care provider provide care for you without an in-person office visit. Telehealth is done primarily online with internet access on your computer, tablet, or smartphone. (telehealth.hhs.gov)

Care involved when a patient/client leaves one care setting (i.e. hospital, nursing home, assisted living facility, SNF, primary care physician, home health, or specialist) and moves to another. (nacns.org)

Transitional care management ensures patients who have a high-risk medical condition will receive the care they need immediately after discharge from a hospital or other facility. Learn more about how to get paid for this service. (aafp.org)