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where we cover interesting and relevant news, insights, events, and more related to the health care industry and pMD. Most importantly, this blog is a fun, engaging way to learn about developments in an ever-changing field that is heavily influenced by technology.

POSTS BY TAG | care coordination



With the creation of MyHealthEData, and through current rulemaking, the Centers for Medicare and Medicaid Services (CMS) is pushing significant new data-sharing requirements into the market.  The new rule opens all types of doors in its effort to improve data transparency and data velocity throughout the system.

The core tenets are:

Ensuring patients have access to all health data where CMS has programmatic authority:

Any payors involved in the following programs are required to have open APIs (Application Program Interfaces): MA organizations, Medicaid programs (both FFS and managed care), CHIP (including FFS and managed care), and QHP issuers in FFEs.

These open APIs will allow patients to empower a vendor to access their claims, encounter data, utilization history, and any clinical health information (such as lab results when available) the payor may have. Payors are also to make their plan directory available through these APIs and have to share care coordination data with each other.

Electronic patient event notifications:  

As a condition of participating with Medicare and provided their EHR has the ability to produce and send an Admit/Discharge/Transfer (ADT) message, it is being proposed that hospitals should send notifications to those practitioners or providers that have an established relationship with the patient relevant to his or her care. (The requirement is waived if the receiving provider can’t receive such messages.)

Prevent information blocking:  

Providers who are not making patients’ clinical data readily available will, essentially, be publicly shamed into compliance as CMS aims to share provider attestations that the provider complies (or doesn’t) with interoperability requirements laid out in updated MIPS rules.  In my opinion, this is a seemingly weak penalty for non-compliance so hopefully, CMS tightens this to improve accountability.

So how might care be impacted by these changes if implemented largely as proposed?  

Where are patients likely to engage with this information?  How about providers?

Patients, to date, have shown little interest in actively engaging with their health care data on their own (consider almost every provider’s struggle to get Portal engagement) - what will Medicare/Medicaid patients do with their claims history?  It’s possible applying algorithms to claims data to identify at-risk profiles might generate patient-level demand but the marketing will have to be focused and on point.  

The first real-world test of the data typically available is Medicare’s Blue Button API (now in version 2.0).  As of October, there were 1,200 software developers in the sandbox and 100 - 200 patients had downloaded their data.  It’s possible this gap between developer engagement and patient engagement represents a lag from the time it takes to create an application to generating demand for the information.  I think it also highlights that age-old health care problem of an abundance of data and little of it valuable or comprehensible to your average individual. At the end of the day, how do you engage a patient to make their best health care choices when those choices are either deeply complex or rarely and erratically occur?

The other audience, of course, is providers.  Claims data provides a history of activity which can complement the clinical care history each participating provider can access.  They can see diagnoses and procedures which both carry useful information in any given provider’s ongoing care of the patient and supplement their clinical inquiries.

The second benefit of having access to claims data is in optimizing HCC scores.  Since a primary input of HCC scores are all the diagnoses a patient accumulates during the year, having access to a comprehensive list of billed diagnoses allows for any given provider to potentially optimize the patient’s HCC scores.  If this market evolves, payors could fully decentralize HCC scoring (with appropriate incentives) to providers. Considering the HCC score paradigm is national, and zero-sum, it can be expected there will be a rush to claim this space and a handful of winners should emerge.

The health care market continues to be pushed to evolve as the population ages and inflation marches on.  You should consider the technology companies you work with and ask if they have the history, the people, and the capabilities to help you navigate a market where changes can dramatically impact your bottom line and your outlook.  At pMD, through our expertise in mobile charge capture, secure clinical communications, and care navigation we strive to meet our customers where their future needs live.  See what we are about at www.pmd.com.


To find out more about pMD's suite of products, which includes our MIPS registrycharge capturesecure messagingclinical communication, and care navigation software and services, please contact pMD.



I actually had to go in for a colonoscopy the other day. The next day when I got home from work, my wife said, "The doctor called with your colonoscopy results. Good news - they found your head.”

All jokes aside, in advance of pMD’s attendance at the upcoming GI Outlook conference hosted by ASGE (American Society for Gastrointestinal Endoscopy) this week, we want to share a little more than just GI-related humor. If your gastroenterology practice is interested in improving efficiencies and ultimately patient care, you have come to the right place!

Our mobile charge capture and advanced rounding tools enable providers to easily capture and submit hospital charges in real-time, reducing charge lag from weeks to less than a day. In fact, gastroenterology groups using pMD have reduced their charge lag from 14 days to just 0.2 days

Our custom suite of powerful, efficient, and intuitive technology allows health care teams to communicate and capture data at the point of care, improving accuracy and ROI. 

For example, an average 50-provider practice can realize close to $400K per year in additional revenue by implementing a proactive process around transitions of care. pMD’s automated discharge alerts and scheduling instructions make managing this process a breeze, helping grow outpatient practices in the process. With the help of our robust analytics dashboard, practices can easily follow up with patients, reduce readmissions, and recognize Transitional Care Management (TCM) revenue.

Ultimately, it all comes down to streamlining physician workflows. When providers and staff are equipped with the right tools to enhance productivity and increase collaboration for rounding and hand-offs, consult notifications, billing and secure communication, they can spend less time worrying about processes and more time caring for patients. 

But don’t just take our word for it:
"The most common question I am asked about pMD has nothing to do with its use; my doctors and staff want to know why we didn't get pMD years ago. Hospital billing lag time and lost charges have all but been eliminated. The secure messaging feature works great on both provider cell phones and staff desktops. We had high hopes that pMD might improve our operations...seamless integration with existing systems and workflows, better secure messaging, and a reduction in lost charges and billing lag time. pMD has surpassed these high hopes and become one of the best investments made in my 25-plus years of managing medical practices."

- Lucien Roberts, Gastrointestinal Specialists, Inc., Virginia

"The doctors love it, we love it! We are much more efficient with pMD. We're able to track charges better, and bridge the gap of missing charges. It's easier to maintain over paper and has made our process so much easier. pMD has helped us reduce charge lag by at least 75 percent. We also love the ability to message within a particular patient record. It helps our messaging organization, and allows for faster messaging overall by not having to retype patient information into the message. Everyone references the correct patient immediately and as a result, responses come much faster.”

Tamra Crespo, Coding Compliance Team Lead, Austin Gastro, Texas

We will be exhibiting at the GI Outlook (GO) Practice Management Conference in the Loews Hollywood Hotel, August 2 - 4. Come stop by booth #4 for a demo! 

All groups are different, which is why we provide all customers with a full workflow analysis and unlimited consultation services. We’ll continue to work with your practice until you see tangible improvements to the key metrics that matter most to you!

For more information click here or contact us directly.

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, and care navigation software and services, please contact pMD.


Benchmarking Length of Stay article


Benchmarking & Reducing Length of Stay in Hospitals

pMD prides itself on helping providers and practices accomplish their goals and measure their quality improvement initiatives. In the inpatient environment, we often work with groups that are interested in tracking patients’ length of stay (LOS) and assessing how their data compares to estimated values for particular medical conditions or patient populations.

While there are many views on which calculation is the most accurate for a patient’s estimated length of stay, for the sake of this discussion, I will use the geometric mean length of stay (GMLOS) as the value associated with the estimated LOS.

What is GMLOS?

The GMLOS is based off of the patient’s diagnosis-related group (DRG), which is a system of grouping together clinically similar patients. Several different classification systems exist with varying levels of grouping precision and levels of specificity. For example, CMS utilizes MS-DRGs (Medicare Severity Diagnosis Related Groups) to assign a specific GMLOS to each DRG in their system.

Why is Length of Stay Important?

When clinically viable, reducing hospital length of stay has been proven to provide both positive results for patients and financial benefits for the institution. In many cases, hospitals do not receive additional reimbursement once a patient’s stay has passed the GMLOS for their assigned DRG.

The DRG, calculated from the patient’s diagnosis, relies on accurate and thorough coding. One study estimated that 40.6% of patients in a specific facility could have benefitted from having a more accurate DRG assigned. Allina Health, a not-for-profit health care system based in Minnesota, has realized a financial gain of 13 million dollars by implementing a length of stay optimization effort across their system.

Methods for Reducing Length of Stay Compared to Benchmarks

Several strategies, such as provider education on statistics and benchmarks, earlier discharge order entry, and increased case management and care coordination efforts, have proven successful for increasing the percentage of patients meeting - or beating - the GMLOS for their condition. However, providing real-time data to care providers stands out as one of the strongest ways to optimize for length of stay. If the care team and administration members do not have a way to access the comparative statistics while the patient is still in the facility, they cannot address this data during their clinical decision-making process, making it impossible to effectively target interventions.

Benchmarking LOS is most useful when the information is supplied in an on-demand manner, allowing educated care teams to use the relevant information when needed. Implementing a system that provides this feedback in real-time can be difficult and involves concurrent coding teams working together with clinical care teams.

Once the data is readily available, health systems can then act to improve it, taking on projects such as selecting specific DRGs to target for improvement and starting conversations between providers and coders when benchmarks don’t seem clinically accurate. In the end, the patient benefits from a more collaborative care planning initiative that takes full advantage of all available information and includes options for care outside of the inpatient environment.

pMD’s Charge Capture, Clinical Communication, and Care Navigation tools all offer the capability to give relevant information to caregivers at the right time, while avoiding cognitive overload. We’ve worked with enterprises to introduce functionality to support their quality initiatives with real-time data. If you’d like to discuss your organization’s current initiatives and goals around length of stay, reach out to us! We’re all ears.

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, and care navigation software and services, please contact pMD.





For those of us who are avid news consumers (myself included), a certain phrase has rapidly been appearing in the headlines with each passing day: the opioid crisis. The opioid crisis has captured the attention of the U.S. government and media due to its expansive grip on the American public and was recently declared a public health emergency by the current administration. This epidemic not only claims the lives of 130 Americans daily but also subjects a burden of nearly $78.5 billion a year on the U.S. economy. Countermeasures to this crisis have been enacted to provide necessary aid to health care providers and those who suffer nationwide. As active participants in health care, pMD is always seeking to provide a product that will positively impact our clients and the patients that they care for. For us to contribute in a meaningful way, we first have to examine the underlying causes of this opioid crisis.

What Caused the Opioid Crisis?

To understand the actions that government and local communities are currently taking, the first thing that must be addressed is the underlying causes and societal impacts of the opioid crisis. Opioids (and subsequent opioid addiction) have had a presence in American health care since the Civil War, beginning with the use of morphine to treat U.S. soldiers wounded in battle. Then in 1898, Bayer Pharmaceuticals released a new drug that was intended to be a non-addictive alternative to morphine: heroin. Heroin was seen as incredibly addictive, with doctors in the U.S. having objections to the drug as early as 1899. The U.S. endured two major heroin epidemics, once during the Vietnam War era and then again during the late 1980s. With the introduction of prescription opioids such as Oxycontin in the 1990s, the numbers of addicted Americans skyrocketed. Today, there is a strong link between opioid overdose and prescription opioids.

To provide some context on the severity of the opioid situation, here are some startling statistics:

Nearly 11.5 million Americans misuse prescription opioids with over 40 percent of all opioid-related overdoses being attributed to prescription opioids.

The CDC states that those who use prescription opioids are 40 times more likely to use heroin compared to 2 times more likely for those who consume alcohol.

The Substance Abuse and Mental Health Services Administration (SAMHSA) finds that more Americans die from opioid overdoses than motor vehicle crashes.

The Midwest has seen a 70 percent increase in opioid overdoses from 2016 to 2017.

Large cities across the country continue to struggle with opioid addiction, as 16 major cities saw a 54 percent increase in opioid related overdoses.

Overall, the United States is taking a major hit from the over prescription and trafficking of pharmaceutical opioids.

Current Response

Recent laws that have been passed to address the opioid crisis include the bipartisan Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. SUPPORT has many potential positive impacts on the opioid crisis, ranging from increasing the amount of first responders carrying naloxone to the expansion of access to addiction treatment for Medicare and Medicaid patients. This law requires state agencies to establish drug management programs, notably state-run databases called Prescription Drug Monitoring Programs (PDMP)PDMPs are increasingly being integrated into Electronic Health Record (EHR) systems, allowing for easy access and real-time updates to a patient’s history. PDMPs are also actively managed by U.S. health departments to help form more effective responses to the crisis using real data.  

pMD Solutions

pMD is passionate about improving the lives of patients and having a positive impact on health care. So, what can pMD do to help with the opioid crisis? Now that all 50 states have functional PDMPs, physicians are required to accurately document patient interaction with opioids in their daily visits. pMD’s customizable software can help groups capture necessary data relating to opioid interactions and pMD’s Care Navigation and Clinical Communication tools would also be an asset to opioid recovery teams throughout the country. Opioid recovery teams are comprised of professionals who cover all the bases of opioid recovery to increase patient success, including behavioral health specialists, physicians, social workers, peer recovery coaches, and even lawyers. pMD creates a space for care teams to successfully track the progress of opioid recovery patients while also communicating with each other on the same platform. This, in turn, allows the health care system to have a more significant impact on the opioid crisis as a whole. For as long as the opioid crisis exists, pMD will continue to find ways to spread awareness and create solutions that will have a positive impact on the U.S. health care system.

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, and care navigation software and services, please contact pMD.









I greatly appreciated Dr. Daniela Lamas’ perspective in her New York Times article, You’ve Detailed Your Last Wishes, but Doctors May Not See Them. Much ink has already been spilled about the failures of the electronic health record to solve the biggest problems facing patients and health care providers today. This article described a particularly tragic failure: a small piece of absolutely critical information was present in the patient’s record, but it was buried in an ocean of text. Nobody saw it during the chaos of an Emergency Department (ED) admission.

Since then, Dr. Lamas has heard about many other “situations in which last minute ‘saves’ through extreme diligence or chance, such as the one I experienced, had led to a good outcome.” This problem is indeed widespread. A 2016 study in the Journal of Patient Safety estimated that medical errors caused between 210,000 to 440,000 deaths per year in the United States, and that total Preventable Adverse Events due to medical errors occur between 2 to 4 million times per year. It’s a staggering number, accounting for up to one sixth of all deaths in our country last year!

In her article, Dr. Lamas proposed some ideas for fixing this buried information issue. The ideas included:

1. “standards for sharing [...] across all electronic records”
2. “all health systems could require identification of a health care proxy for all patients”
3. “patients should be able to access their health records through a patient-facing interface, send in their own directives, or even update related notes”
4. “all related advance care planning documentation should be in one place in the medical record and accessible with one simple click of the mouse”

Interestingly, three of these wouldn’t help with a situation like this where the information was already present in the record, yet buried out of sight. And the fourth - putting advance care planning documentation in a single place - had already been done at Dr. Lamas’ hospital. The physicians just didn’t use that screen because “habits are hard to break, and without a clear set of incentives, training, and ongoing education, doctors (myself included) continue to record information about end-of-life conversations in progress notes, where they are not readily available”. When the EHR documentation burden is already so heinously high, it’s easy to see how caregivers wouldn’t rush to embrace yet another screen added into the mix. After all, it’s not reasonable to expect the Electronic Health Record to transcend or change its nature, which is, in Dr. Lamas’ words, “a clunky online version of a paper chart”.

She did reference another approach to solve this problem, “clever patient apps that work outside the electronic record”. For an app to help in such a situation, it must not live only with a single person. The patient may be unconscious or may not have their phone with them when they’re admitted. Their health care proxy may not be reachable right away, or perhaps the patient didn’t designate one. So to make absolutely sure that any health care provider who sees the patient can access this information, the app must live with everyone possible who is involved with the patient’s care. The patient, their family members, their health care proxy, each of their physicians, and perhaps most critically of all, their care navigator.

Many of the very sick patients such as the one in Dr. Lamas’ story already have a care navigator assigned to help them navigate through our fragmented health care system and to quarterback the communication among different care teams at different institutions. This person is like the patient’s health care guardian angel. In most cases, they know the patient better than any one physician.

As long as the care navigator finds out immediately when the patient hits the ED and which doctor is seeing them, they can spring into action and make sure the really important information gets to the right person in a timely way. With pMD® Care Navigation™, care navigators can find out instantaneously when the patient is admitted to the ED and have easy access to a concise summary of the truly critical information about the patient’s care plan and decisions.

If care navigators have critical information at their fingertips, are empowered to intervene with exceptional communication software, and find out automatically when patients have their moment of crisis, then we can let the Electronic Health Record go back to doing what it was always designed to do: being the digital filing cabinet. It’s time to move forward to the next generation of software for patients, families, physicians, and especially care navigators.

Find out more about pMD's suite of products, which includes our MIPS registry, charge capture, secure messaging, clinical communication, care navigation, and clinically integrated network software and services, please contact pMD.



Health care practices are very active in a wide variety of reporting and often times report to various different organizations in order to track population health, positive outcomes, and quality of care. Some of these reporting mechanisms are hosted by government agencies, highly-regarded news sources, specialty councils, and national organizations. One such type of reporting is through a Clinical Data Registry. These type of registries are made up of similar medical practices and specialties to gain a better understanding of the care given to patients. This also allows groups to benchmark their organization against other participating groups. These registries collect information on the specified health care population and utilize the information to track trends in how disease is managed and how it is progressing within a population.

Why Participate in a Registry?

Participation in a registry allows organizations to gain additional benchmarking and provides access to best practices when looking to improve clinical outcomes and decrease cost. Through this registry data and research, clinicians and scientists will be able to establish patterns based on disease progression, current medical standards, and patient outcomes to determine and share best practices within a community of similar health care organizations. The hope is that this invaluable insight will progress beyond a zip code and expand into the big picture of national and global health care.

Here are just a few of the many registries to choose from:

US Wound Registry
National Palliative Care Registry
National Radiology Data Registry
Lung Cancer Screening Registry
National Cardiovascular Data Registry

Tracking and Reviewing Registry Data

Tracking data, compiling answers to survey questions, and reporting to an organization may sound a lot like incentive-based programs such as MIPS reporting. While participation of these programs are required by the government, reporting to clinical data registries is completely optional and benefit the group of health care organizations that participate by allowing them to see where they stack up against their peers. While these registries may vary in reporting mechanisms, the format of reporting is generally the same. Typically, there is an annual survey that would need to be completed, which always includes the requested data points. Health care organizations will review various metrics that are both clinical and care-based such as readmission rates, standards of care, diagnosis at the time of consult, patient engagement, etc. from the previous year and submit that data to the registry. This may require a need to do an in-depth review of clinical care, social work, and assessment of everyone who is part of the patient’s care team to get an accurate depiction of what is involved with caring for these populations.

How Can pMD Help?

Combing through a full year’s worth of data across multiple teams can be daunting, requires a considerable investment of time, and may leave you thinking, “There has got to be a better way!” Here at pMD, we are working with health care organizations who are at the forefront of population health and participate in these registries. We work closely with physician teams to capture more than just billing information but also additional clinical and pertinent information as well.  pMD has been well-established in working with physicians for tracking this type of information.

Now, with the use of our care coordination product, we are able to assist care coordinators and social workers with securely communicating with patients and their physicians and capture valuable information that would otherwise be lost in the sea of notes come time for reporting.

If you or your organization would like to hear more about what we are working on here at pMD, including our MIPS registry, charge capture, secure messaging, and care coordination software and services, or what we can do to help you achieve your goals, we invite you to reach out to us.
As a software engineer at pMD, I get to straddle the cutting edges of two very different industries: health care and technology. I’m familiar with how quickly the technology world moves -- developers jumping on a new front-end technology every other day, “sprinting” through “agile” hoops at the speed of light. But I’ve been surprised to learn how thoroughly the health care environment is also evolving. I’ve learned that over the next few years, physicians will be facing fundamental changes in the way they see and treat patients. It has been one of the most interesting parts of my job to not only learn about these changes, but to help providers transition to the health care environment as it transforms around them.

With value-based health care on the horizon, providers will need to bring the patient into the center of their care. For the more than 100 million Americans with chronic illnesses, for example, the occasional face-to-face encounter with a provider might not be enough. Obviously, for those types of patients, providers must think beyond the 30 minute annual checkup; with constant management of medication, treatment, and services. In today’s day and age, providers often have difficulty bridging communication gaps, leading to inconsistent data, increased expenses, and poorer outcomes for their chronically ill patients.

We are trying to solve that problem at pMD, and to help providers proactively coordinate their patients’ care. Every new feature we are working on supports providers as they take on this new paradigm shift. One of the simplest ways we help providers is by showing them how they can get reimbursed for adapting to this new, patient-centric health care model. For example, since 2015, Medicare has reimbursed providers who offer at least 20 minutes a month of non-face-to-face medical care to patients with two or more chronic diagnoses, through CPT code 99490. For our providers -- who have been using pMD's charge capture tool to record services outside of face-to-face encounters like medication reconciliation review and care coordination, and may soon start to use pMD for patient education -- this could prove to be a fruitful change that helps them transition to tomorrow’s health care system.

Last week eight of my colleagues and I were in Anchorage, Alaska working with physicians, nurse practitioners, social workers, care coordinators, patients, and more. Although we were meeting about an array of different items, including building and enhancing care communities, charge capture, secure messaging, and clinical data exchanges, they all share the same common goal of working in collaboration to fill the gaps in patient care.

Patients that are “frequent flyers” of hospitals often suffer from chronic conditions, bounce between many specialists, and are at higher risk of costly readmissions. Due to the fragmented nature of their care it can be difficult for caregivers to receive the right information about the patient at the right time. Big EHRs are drowning in data and are not always reliable to get the providers the bottomline, clinically relevant information they need in a timely fashion.

Doctors and staff throughout Anchorage are coming together in a grassroots effort to make change happen and improve the care that their patients are receiving, regardless of which provider in the community is delivering it. Connecting everyone together around the patient decreases medical costs, decreases duplicate tests, cuts down on medical mistakes, and it saves the patients and doctors valuable time, ultimately leading to better overall care.

This model of coordinated care in Alaska however, is not unique to Alaskans. What the caregivers in that part of the country have been able to do is create a connected care community where they are coordinating the care around the patients, especially as the patients move between providers and facilities. We’ve heard from customers in other areas of the country about this same mission of connecting the different caregivers together around the patient instead of the patient around each of the caregivers. An important part of the solution is having a secure channel to share information quickly and seamlessly, and at the foundation is the concept of one patient no matter how many doctors they see. pMD continues to be an integral communication platform for care teams, allowing them to send quick, secure, valuable information, and brings together a community so they can start talking with one another.
My best friend and I were catching up with each other when he says, "My mother was just diagnosed with cancer".

Then I felt it. That unmistakeable sinking feeling you get when you learn for the first time that a loved one has been diagnosed with a serious life threatening illness.

After learning this, we began talking through the experience from his mother’s perspective as a patient. It was interesting and informative but also incredibly frustrating. One recurring theme during our conversation was the fact that people naturally turn to friends and family for advice and support when health problems arise. This personal support network is then very likely to look online for additional information and potentially seek out people who share the same health concerns. I started to think about how pMD might be able to help.

One of the challenges we are solving at pMD is the coordination of patient care. We're learning that care coordination involves more than just the flow of information between patients and health care professionals. It also involves communication between patients and their advocates, and even patients and their peers.

Enabling the people involved in a patient’s care to turn to different sources for different types of information is incredibly powerful. And by including the patient's support network as part of their health care team, we can help patients receive practical advice for coping with day-to-day health situations or even receive emotional support from the people who are best equipped to provide it.

Health professionals remain an important, if not the most important, source of information for patients. But a patient’s peers are also a significant source of influence that can alter the course of a patient’s road to recovery.

Chronically ill patients in many parts of the U.S. face myriad complex challenges when it comes to coordinating their own health. About a month ago my colleague and I traveled to Anchorage, Alaska to meet with some of our more remote customers up north (we didn’t meet any moose this time). I had heard and read great things about the work that was happening with Alaska Innovative Medicine (AIM), which uses pMD’s care coordination and secure messaging tools to manage many of the chronically ill patients in the region. However, it’s one thing to read about the impactful and forward-thinking work that AIM is doing with the patient community in Anchorage, but quite another to experience it first-hand.

AIM partners with local primary care providers, specialists, case managers, social workers, home care nurses, dietitians, pharmacists, and others that are involved in a patient’s care. Their goal is to improve patient care and lower health care costs by preventing hospital readmissions, preventable ER visits, and reducing hospital stays. We had the opportunity to sit in on one of AIM’s meetings as they discussed the work they are doing with some of the other caregivers in the community.

The AIM team explained how they help patients manage their care when they are discharged from acute care facilities so they don’t have to manage their health on their own. They help patients with diagnosis education, interpreting hospital discharge instructions, medication education and reconciliation, connecting patients with additional caregivers, and integrating personal goals into health care plans. The AIM team acts as a safety net to fall back on if something isn’t working with a patient’s care.

Navigating the health care system is difficult to begin with, especially when a patient isn’t feeling well. And patients can feel very alone after they go home and try to manage their care themselves. A few patients who work with the AIM team were quoted as saying, “It helps when somebody cares” and “I now have someone to call when I need help. Thank you for not giving up on me.”

It was encouraging to see how AIM is reconnecting a fragmented health care system piece by piece. They are engaging and empowering patients, building up patient support systems to provide more successful health outcomes, and creating a more cohesive provider communication channel. pMD is excited to be partnered with AIM to improve the health care experience for Alaskans!