23-882 Expect Better Engagement With Virtual Care Post-Hospital Discharge Program
Date: 08/11/23
New program aims to reduce avoidable readmissions for high-risk members
California Health & Wellness Plan’s (CHWP’s) virtual care post-hospital discharge program now offers a telehealth solution to help reduce readmissions after inpatient discharge.
How it works
Within seven days of discharge from inpatient hospitalization, a CHWP care manager offers members at high risk of readmission help in getting a follow-up visit with their primary care physician (PCP). If the PCP is not available within seven days, if the member lacks a PCP or if the member does not wish to see their assigned PCP, the care manager offers the member a new telehealth follow-up service using an experienced virtual care provider, Telehealthdocs.
Founded in 2011, Telehealthdocs Medical Group has been a pioneer in telehealth services from Bakersfield, California. Their team of California licensed providers offers expert virtual care.
Members opting for Telehealthdocs' post-discharge services will be smoothly referred by a care manager. Telehealthdocs ensures solid care coordination by actively collaborating with PCPs and diligently sharing telehealth records.
Members may choose you as their new PCP
You may receive new patients through this program, as the service can help a member find a PCP if the member doesn’t have one.
How the program helps you/your practice
The virtual care post-discharge program can help physicians and other providers, as Care Management follows members through the post-discharge process to ensure members establish care with PCPs.
The program can:
- Identify at-risk members to help prevent unnecessary readmissions.
- Increase patient engagement and provide guidance to ensure members are adhering to discharge orders.
- Establish and reinforce the PCP-member relationship.
- Connect a member to you as their new PCP if the member doesn’t have one or wishes to change PCPs.
- Help close care gaps for you/your practice.
- Perform medication reconciliation within seven days of discharge.
- Offer an alternative to members when their doctor is not available within seven days post-discharge.
- Work to save you time by identifying at-risk members and avoiding unnecessary readmissions for complex, time-consuming cases.
How the program helps members
The program helps members conveniently access care after discharge by giving them an alternative when they are experiencing mobility issues or transportation challenges after hospitalization, or simply prefer the convenience of telehealth post-discharge.
The program offers members:
- Assistance in scheduling a follow-up visit with their PCP.
- Help setting up a post-discharge, follow-up telehealth visit, if the member cannot see their PCP within seven days, if the member lacks a PCP or the member does not wish to see their assigned PCP.
- Assessment of health status.
- Review of discharge orders, instructions; address data gaps.
- Medication reconciliation.
- Interim treatment and avoid interruption of care until the member can see a PCP; improve access to care.
- Clarification of home health visits/DME services/follow-up testing and appointments.
- A home safety assessment.
- Community resource referrals.
- Member/family education.
- Review of what to do if problems arise.
- Reduced travel time and costs.
- Help finding a PCP if the member doesn’t have one or wishes to change PCPs.
Additional information
Providers are encouraged to access CHWP’s provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.
This Information applies to Physicians, and Independent Practice Associations (IPAs).