Chronic Care Management

Telehealth program option gives customer choices

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The Western Reserve Area Agency on Aging (WRAAA) announces a new Telehealth Program. The Telehealth Program focuses on Case Management, Transition of Care, Health Coaching, and Community Linkages. This program aims to reduce health disparities and monitor health conditions to avoid unnecessary ER visits and hospital admissions.

How the Telehealth Program Works           

When a patient signs up for the Telehealth Program, the patient will receive, at NO COST, a tablet, blood pressure cuff, a thermometer, scale, glucometer, and oximeter. The assigned Care Coordinator will be able to assist with monitoring the patient’s vitals and provide coordination with medical professionals.  

Program Eligibility Requirements
  1. Medicare Part B
  2. Secondary Insurance
  3. Two chronic conditions expecting to last more than six months.

Programs

Medicaid Waiver Application Assistance

If a patient meets the previously mentioned eligibility requirements and is interested in waiver services but unsure how to navigate the system, please make a referral. If enrolled, the Telehealth Care Manager will work with the patient to coordinate financial eligibility with Job and Family Services while coordinating care with WRAAA's pre-enrollment unit and ADRC. 

Case Management

The program will assists members with multiple chronic conditions and frequent use of the emergency room and hospital. WRAAA case managers will coordinate care, manage transitions between levels of care, and work collaboratively with all providers to identify the best care plan possible. Areas of focus will include addressing members' psychosocial barriers to health condition improvement, medication compliance, and member goals, resulting in decreased emergency room and hospital utilization.

Transition of Care

Assists members to ensure care is uninterrupted when moving between care settings or to the home. Care settings may include hospitals, mental health facilities, substance use treatment facilities, skilled nursing facilities, long-term care facilities, rehabilitation facilities, and correctional facilities. Areas of focus include coordination of services, reviewing discharge plans, and possibly connecting members to longer-term care management programs.

Health Coaching

Helps members at risk for or diagnosed with adult and pediatric asthma, congestive heart failure, diabetes, and COPD. Health Coaches provide education, coaching, and support to members to help them understand and manage their conditions.

Community Linkages

Assists members by addressing social determinants that have an impact on member health. The care manager provides care coordination and referral services to members requiring navigation assistance and access to plan and community-based benefits and resources.

 

To make a referral please complete and submit this form.

To make a referral email: telehealth@areaagingsolutions.org for assistance.