Connected Care Institute

Patient Care Comes First

Being a member of our Connected Care Institute enables you to have access to our Chronic Care Management (CCM) team,  Remote Patient Monitoring (RPM) team, and Transitional Care Management (TCM) team. Each team helps the Physicians, NP’S, And PA’s  at Lake Country Medical Group oversee patients with chronic medical conditions in order to help improve the quality of their lives and achieve better health outcomes.

A woman getting blood pressure taken

Connected Care Institute and Medicare are partners in assisting with Chronic Care Management, Remote Patient Monitoring, and Transitional Care Management.  

Below we describe the role of each of the teams that make up the Connected Care Institute

If you have two or more serious chronic conditions that you expect to last at least a year, Medicare will pay for a health care provider’s help to manage those conditions. This includes a comprehensive care plan that lists your health problems and goals, other providers, medications, community services you have and need, and other health information. CCM is recognized as a critical component of primary care that contributes to better health and care for individuals.

Remote Patient Monitoring (RPM) enables healthcare providers to monitor and manage patients outside of conventional clinical settings. RPM uses connected medical devices to measure and collect data from patients in a remote location, such as their home.  The data is transmitted electronically to the RPM software that allows the patient’s care team to view it, instantly.  All of this empowers the care team to proactively assist their patient’s health and intervene when it really matters most.

We aim to improve patient outcomes by getting a ‘full picture’ of a patient’s medication regimen.  We conduct extensive medication reconciliation appointments, check for duplicate therapies from multiple providers, and conduct drug-drug interaction checks that include over the counter supplements/drugs.  We also look for opportunities to improve patient health by documenting vaccine needs, suggesting medication changes to better adhere to industry best practices while also looking for cost-saving opportunities to reduce out-of-pocket costs.

Transitional Care Management (TCM) covers if you are returning to your home in the community from the hospital or from a skilled nursing home facility. The TCM team make sure you receive an in person/in office visit within 10 days of your discharge.  We also will make sure your medications are reconciled and your patient chart is up to date with the most recent patient summary from your hospitalization.