Disease Management Programs
Active Wellness offers the first Disease Management Program that provides comprehensive, coordinated, and continued care by a
Personal Care Team. The care is based on clinical protocols and best practice guidelines and clinical care pathways assisted
with NLP. NLP allows generating actionable intelligence from the text being entered by patients, care coordinators, home care
givers, and nurses. This is specifically designed for documentation of problems remotely and is especially helpful to capture the
changing conditions of a patient who has diabetes, COPD, asthma, CHF and behavioral health. Our Disease Management Program
draws on the best in class protocols to provide remote care. We build a ring of care around the patient with home care and
personal care teams to give you a great experience and keep you out of the hospital.
Using an intelligent interactive platform with telehealth solution as a key element in providing health across the continuum of care. We provide better
patient experience, expanded touch points, and significantly reduced costs. We support newly-diagnosed patients as well as patients at every
stage of their diseases. This includes both short-term programs to reduce hospital readmissions and longer-term proactive disease management.
Our Disease Management Services Offering
Our endeavour: Keep you healthy and out of the hospital.
Chronic Disease Management: This program is ideal for patients who have been diagnosed with a chronic disease. The program helps
build and deliver total care plans by care teams.
Create Comprehensive Health Profiles: Comprehensive Health Risk Assessment and getting test / vitals measured and review of problems help
care teams to identify & address co-morbidities, medication therapy, build Total Care Plans.
Dedicated Disease Management Program: Comprehensive care teams supported by nurses, doctors, pharmacologist and allied healthcare
professionals available 7 days per week from 9 a.m. to 5 p.m.
Triage: 24/7 nurse triage services available for any symptomatic patient calls outside of dedicated Disease Management coverage hours
Event Escalations: Physician escalation 24/7 for events requiring interventions. (optional)
Remote Monitoring: Device monitoring & Coordination with device suppliers and systems managers. Upload the data into your PHR.
PHR: A Personal Healthcare Record where all episodes of care and the encounters therein are documented. These cover Wellness, Prevention,
Risk Assessment, Sick event and disease-related encounters. The single data recording and reference point for all members of the care
teams from nurses to Primary Care Physicians and Specialists.
Patient Web portal: Providing secure access for patients and their care team. The online interactive tools allow the patient to manage his
health, record problems, get answers, get advice and have care teams manage their health 24x7. Appointment Scheduler, Communication Manager
allow secure communication.
Social Network: Allows consumers to connect and share their experience with patients having similar problems and can join groups of
Comprehensive Health Management Tools: Interactive dashboards, real-time alerts, identification of gaps in care, escalations of
potential problems, proactive interventions and Care Plan Modifications supplemented by health and disease awareness coupled with
care teams' communication.
Remote / Home Monitoring: Remote device monitoring (when clinically appropriate). At an additional cost, Active wellness can supply through
its partners complete procurement and management of medical devices.
Proven Results In Disease Management
Active Wellness Disease Management Program involves managing patients with all stages of chronic disease. Health management starts with
early detection and then comprehensive management of chronic disease that give better health outcomes, lower incidence of hospitalization,
lower costs, increase productivity.
The disease management ranges from Self Managed Care to Managed Care where a personal Care team works with the patient to manage his
health need. In both, you can undertake telehealth consultations.
The unique and technology platform driven by Artificial Intelligence helps build personalized Total Care Plans. The technology is
wrapped by a set of services that enhance the patient experience and provide better health outcomes. The patient built in robust tools
provides a single solution for all health needs.
Managed Care brings continuous availability of health counseling and monitoring to prevent / reduce adverse events.
This is at costs that are about half of the price when compared to standalone visits by a care team member.
Such comprehensive approaches over a three-year period, have demonstrated, that if used correctly, it delivers ROI of more than 200%
for remote nurse advice programs and saved our hundreds of millions of dollars. The patient value is evident:
14% reduction in elective admissions
14% reduction in bed days.
45% reduction in mortality rates.
Telehealth Solutions For Behavioral Health
Our Telehealth Solutions for Behavioral Health Program offers personalized supportive counseling to individuals coping with a mental
illness, a behavioral health issue, and addiction. The program is designed to support patients diagnosed with a mental illness
including those transitioning back into their community post-hospitalization. Caring, experienced staff offers hope by providing the
tools needed to cope with their problem and progressively move to have healthier lives. It is a total behavioral health approach.
It is not just counseling to treat a condition, but also to address the individual’s environment, emotions,
physical, and behavioral health.
Providing appropriate, integrated telehealth services supports recovery and minimizes the effects such disorders have on family,
friends and community.
Telehealth Solutions For Behavioral Health: What We Provide
Assessment: Comprehensive needs assessment
Care Plans: A continuity of care plan enables care teams to identify supplementary community programs that would be helpful
Counselling: Regularly scheduled supportive counseling sessions with flexible program durations and levels of service available
Care Team: Dedicated case management nurses available daily from 8 am to 5 pm ET 7 days per week
Triage: 24/7 Triage Nurses on call outside of dedicated case manager coverage hours
Escalation: Escalation to alternate mental health professionals available as an optional add-on
PHR: A Personal Healthcare Record where all behavioural encounters covering counselling and medications' if any added are recorded.
Improvement goals set and then tracked. This also helps create a healthy repository of your care documents such as test,
prescriptions, etc. The documentation of your health covers Wellness, Prevention, Risk Assessment, Sick event and other disease
-related encounters. The single data recording and reference point for all members of the care teams from nurses to Primary Care
Physicians and Specialists.
Private Consultations: Secure behavioural health telehealth consultations in the privacy of your home. Only authorized persons can
access your medical records. The Care teams (physicians, caregivers) have a web portal access to review your conditions and assign
tasks to modify Care Plans based upon their reviews after a consultation.
Education: Supplementary health education is provided that helps you better understand your condition and how to address them.
Comprehensive Health Management Tools: Interactive dashboards, real-time alerts, identification of gaps in care, escalations of potential
problems, proactive interventions, and Care Plan Modifications supplemented by health and disease awareness coupled with care teams'
Help individuals manage their illnesses in order to prevent deterioration or hospitalization
Assist individuals with determining goals and actively participating in their recovery planning processes, so they have the right
skills to live, learn and work in the community as independently as possible
Provide emotional, educative and case management support in a safe, dignified and therapeutic environment even in at their homes.
Ongoing monitoring and review allows tracking and Monitoring of conditions to know for early signs of deterioration in health and
proactively communicate immediately with the treating provider that may lead to a modification in the care plan.