Chronic Care Management

Our CCM platform manages your chronic care patient populations in one organized solution. Our software has the tools needed to screen for eligibility, obtain program consent from the patient, generate and modify Care Plans, log and track minutes while communicating with patients and others tied to the care of the patient. Through our training and implementation process, the our CCM program can be managed by your medical staff or by MDSS' experienced Call Center to manage patient follow up.

MDSS acts as an extension of your practice, available for your patients 24/7. We follow your protocols to mirror the personality of your practice, build relationships with your patients and their caregivers, and effectively deliver Chronic Care Management and other care coordination services on your behalf.

MDSS offers a Remote Patient Monitoring solution that enables physicians and their staff to monitor physiological data from devices placed in the patient's home. An RPM Dashboard and automated alerts ensure that every patient is followed at the right time while also ensuring that Medicare's requirements for reimbursement are met. Our tools include a person-centered self-assessment of their conditions to motivate patients to stay focused on their health and take their readings from the comfort of home, knowing their provider is receiving the results within a few minutes.

Our RPM is fully integrated into our Chronic Care Management module, eliminating duplicate data entry, and providing you with the data needed for care planning specific to each patient's needs and goals.

RPM allows clinicians the ability to deliver high quality care to a larger number of patients while giving the patient the flexibility to do their regular testing at home. This provides accessible test results monitored by your staff or our Call Center Team, while bringing new revenue sources to you from Medicare, Medicaid and possibly Private Payers.

Patients who participate in an RPM program benefit from increased proactive monitoring and greater oversight of their health. Providers recommend the program to help reduce or prevent hospitalizations, trips to the Emergency Room and adverse health events while providing additional access to care and strengthening the patient’s relationship with their healthcare provider. 

Our Annual Wellness Visit solution helps you easily manage all the steps to complete the visit and get paid by Medicare. Our tools enable you to check eligibility for when and for what type of visit is due, and to proceed through the visit without missing a step. Our tools manage the health risk assessment, clinical intake, personal prevention plan and provider review with a complete report that can be handed to the patient.

The Health Risk Assessment's intuitive design keeps the patient engaged and allows the questions to be answered by the patient online either as part of a telehealth visit or in advance of the appointment. The clinician is guided through a review of the patient's responses to the HRA, the clinical intake process, MiniCog and TUG tests.  Information entered during one visit is automatically stored for review and update in subsequent years.  

The Annual Wellness Visit (AWV) program integrates with existing Electronic Health Records (EHR) software to provide Medicare Beneficiary Management. Our tools manage the patient risk assessment, clinical intake, and provider review.

The Patient's Risk Assessment can be completed on a mobile device with an intuitive interface that helps keep the patient engaged and allows for completing the risk assessment online via Telemedicine or at your practice or clinic.

Our AWV module is integrated to our Chronic Care Management tool so that information in common, such as medications, update seamlessly between modules.  As part of the workflow, practices can ask qualifying patients to enroll in CCM  and they are registered into that module for care management without duplicate data entry.