top of page
image.png
image.png
image.png

The patient is enrolled in a 12-week, 36-session pulmonology and cardiology rehab program that takes place over telehealth. The program includes three sessions a week, up to an hour and a half per session, with patients exercising either on a bike or a rollator up to 40 minutes a session. During this time, remote patient monitoring (RPM) is conducted, including pulse oximetry and blood pressure measurements. The patient is required to report their blood pressure and pulse oximetry readings before being admitted into each session. If there are any issues with these readings, the patient is coached before they can enter the session. The patient is also not allowed to leave the session if their pulse oximetry or blood pressure readings are not within acceptable ranges. In such cases, they are asked to stay with one of the respiratory therapists until their vitals reach appropriate levels. If necessary, the pulmonologist or cardiologist will intervene.

The patient's primary care physician (PCP) is involved in the referral process for the rehab program, and the PCP is updated on the patient's progress throughout the program. After the 12-week rehab program, the patient transitions to remote therapeutic monitoring (RTM) and potentially chronic care management (CCM) services, which may be provided by a virtualist if the PCP is not offering these services. The patient's insurance covers the rehab program, and the patient may also be eligible for additional services such as RPM and CCM.

 

1. Chronic Obstructive Pulmonary Disease (COPD)
- Enroll the patient in a 12-week, 36-session pulmonary rehab program via telehealth
- Monitor patient's vitals, including blood pressure and pulse oximetry, before and after each session
- Coordinate with the primary care physician (PCP) for regular updates on the patient's progress
- Upon completion of the rehab program, transition the patient to remote therapeutic monitoring (RTM) and care coordination

2. Congestive Heart Failure (CHF)
- Enroll the patient in a 12-week, 36-session cardiac rehab program via telehealth
- Monitor patient's vitals, including blood pressure and pulse oximetry, before and after each session
- Coordinate with the primary care physician (PCP) for regular updates on the patient's progress
- Upon completion of the rehab program, transition the patient to remote therapeutic monitoring (RTM) and care coordination

3. Remote Patient Monitoring (RPM) and Chronic Care Management (CCM)
- Assess the patient's eligibility for RPM and CCM services
- Coordinate with the primary care physician (PCP) and virtualist for appropriate care management programs
- Monitor patient's adherence to medications and daily exercises
- Escalate any issues to the PCP or virtualist as needed

4. Expansion of Services
- Focus on expanding services to states with licensure, including Florida, Texas, and the Midwest
- Hire additional providers and staff as needed to accommodate patient volume
- Collaborate with insurance agencies to engage members for pulmonary, cardiac, RPM, and CCM services
- Assess the quality of leads from MCARE and predict patient volumes for planning purposes

5. Bilingual Patient Support
- Explore options for accommodating Spanish-speaking patients in the program
- Develop a script for contacting patients and coordinate with the outreach team for patient engagement

6. Staffing and Patient Load Management
- Determine the appropriate staffing levels based on the number of episodes per patient per month
- Hire additional nurses or medical assistants as needed to manage patient load

- Provide dedicated staff per contract, ranging from 1 to 150 or 1 to 300 patients, depending on the acuity of the patients

 

 

 

 

 

 

 

Dear Lifetime Vitality,

Thank you for participating in your recent telehealth visit with our team. We commend you for taking proactive steps toward managing your health and are pleased to have you enrolled in our comprehensive pulmonary and cardiac rehabilitation program. Your commitment to improving your well-being is truly admirable.

To ensure you have a clear understanding of the program and your role in it, please review the following instructions:

1. Attend Telehealth Sessions: Participate in the 12-week, 36-session rehabilitation program, attending three sessions per week for up to an hour and a half each session.

2. Exercise Regimen: Engage in the prescribed exercises, which may include using a bike or a rollator for up to 40 minutes per session.

3. Vital Signs Monitoring: Before each session, report your blood pressure (BP) and pulse oximetry (pulse ox) readings. If there are any issues with your vitals, you will receive coaching before you can proceed with the session.

4. Post-Session Protocol: At the end of each session, ensure your pulse ox and BP readings are satisfactory. If not, you will be asked to stay online with a respiratory therapist until your vitals stabilize.

5. Referral and Evaluation: Ensure that your primary care physician or home health physician has provided a referral for the program. The pulmonologist or cardiologist will perform an evaluation before you are enrolled.

6. Remote Patient Monitoring (RPM): Engage with RPM during the sessions, which includes monitoring of your pulse ox and blood pressure.

7. Transition to Remote Therapeutic Monitoring (RTM): After completing the 12-week program, you will transition to RTM, where your exercise and medication adherence will be monitored as part of ongoing care coordination.

8. Insurance and Payment: Verify that your insurance is accepted by our program. We accept most major insurances and will work to get in-network if necessary.

9. Follow-Up Care: After the rehabilitation program, you will continue to receive follow-up care, which may include RPM, RTM, and Chronic Care Management (CCM) as needed.

10. Communication with Primary Care Physician (PCP): Stay in touch with your PCP regarding your progress and the transition to RTM or CCM services if they are not provided by your PCP.

11. Language Preferences: If you prefer to communicate in Spanish, please inform us so we can accommodate your needs.

We are dedicated to supporting you throughout this journey and are here to assist with any questions or concerns you may have. Please do not hesitate to reach out to our team for further clarification or support.

Wishing you the best of health,
[Provider's Name]
[Provider's Contact Information]

SERVICES    I   REFERRAL    I    PATIENT CONSENT    I     DESKTOP ICON     I     REVIEW 

 


 

Harshini "Hershey" Jayasuriya, MD, FAAFP/ Medical Director

harshini.jayasuriya@bridgecarespecialists.com I Mobile: (517) 258-0102

 

BridgeCare Specialists of Michigan

Michigan's Virtual Discharge Clinic

Office: (517) 258-0344 | Fax: (517) 879-0374

BridgeCareSpecialists.com

 

 

 

 

 

 


 

BridgeCare Confidentiality Notice - The information enclosed with this transmission is the private, confidential property of the sender, and the material is privileged communication intended solely for the individual indicated. If you are not the intended recipient, you are notified that any review, disclosure, copying, distribution, or the taking of any other activities relevant to the contents of this transmission is strictly prohibited. If you have received this transmission in error, please notify us immediately at contact@bridgecarespecialist.com.

bottom of page