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Protocols for Remote Patient MonitoringAn agreement between _______________________________ (“Practice”) and BlueStar Telehealth for the provision of Remote Patient Monitoring (RPM) services. The parties agree to the following:BlueStar will:Monitor patient RPM data to fulfill the requirements of CMS CPT Codes 99457 and 99458.Perform such monitoring with Qualified Healthcare Professionals (QHP). The BlueStar monitoring team includes, and is led by, Registered Nurses. However, BlueStar cannot guarantee that all monitoring will be provided by RNs. Interact with patients and escalate issues to the Practice staff per this agreement.Document interactions with patients in the VitalCare system as required by Practice and payer for payment of the codes in 1(a) above.Provide monthly documentation and backup data to allow the Practice to bill CMS as appropriate, to include recordings of phone calls for patient interactions, if required.The Practice will:Approve the following protocols, as enumerated in this document:Section 1: Recommended Periodicity for ReadingsSection 2: Standards for Green/Yellow/RedSection 3: Escalation and Notification RulesSection 4: Doctor-Approved QuestionsSection 5: Rules for Calling 911Section 6: Actions for Patient Non-ComplianceNotify BlueStar in writing of any changes to the above orders, by executed a modification to this document.The Parties agree that:RPM services are designed for chronic care management, to identify trends related to the ongoing management of a patient’s health. RPM is not hospital-at-home, or personal emergency response system, or 24/7 service.Bluestar is neither a medical provider nor a medical practice, and does not provide medical advice. RPM monitoring services are provided for informational purposes only, and do not constitute medical advice or diagnosis.The RPM data may be subject to error, based on the patient’s skill in taking measurements, and the normal variation based on the instrument being used.RPM services are typically a day-plus-one review. BlueStar staff will be reviewing data during normal working hours on working weekdays. The Parties have previously executed two agreements, which further memorializes their relationship: the Telehealth Services Agreement, and the HIPAA Compliance Agreement (Business Associate Agreement)These rules apply to all patients being monitored for the Practice, and will not be modified on a patient-by-patient basis.Agreed to this ______ day of _____________________:PRACTICEBLUESTAR TELEHEALTH____________________________________________________________Authorizing Physician SignatureAuthorized Manager Signature____________________________________________________________Printed Name / TitlePrinted Name / TitleSection 1: Recommended Periodicity for ReadingsParameterPhysician Instructions / Desired Measurements per DayParameterPhysician Instructions / Desired Measurements per DayBlood PressureSPO2 (Oxygen)TemperatureGlucoseHeart RateWeightPeak FlowRespiratory RateOther:Other:BlueStar will recommend to patients:That they take their vitals at least once per dayThat they should check with their doctor for any specific direct orders.For those taking blood pressure medication, that they take measurements before and after taking medication.That if they are feeling symptomatic, that they should take their vitals to provide information to support clinical followup.That when possible, all measurements should be done when the patient has been at rest for a minimum of 30 minutes.Section 2: Standards for Green/Yellow/RedThe following are the standard values BlueStar’s monitoring team uses to determine patient status. The standard rules will be used unless modified by the Authorizing Physician below:Standard Rules:ParameterGreenYellowRedPulse Ox>95%91-94%90% or lowerHeart Rate (bpm)60 - 99High: 100 - 119Low: 50 - 59High: 120 or higherLow: 49 or lowerBP: Systolic100 - 129High: 130 - 180Low: 91 - 100High: 181 or higherLow: 90 or lowerBP: Diastolic60 - 80High: 80 - 89Low: 50 - 60High: 90 or higherLow: 49 or lowerTemperature (°F)97.0 – 98.999.0 – 101.9102 and aboveWeight (CHF only)Gaining 3 pounds in 24 hours, or 5 pounds in a weekBlood Glucose (mg/dl)40 or lower500 or higherPeak FlowRespiratory RateOther: _________Other: _________Specific Modifications for this Practice: (if none, leave blank)ParameterGreenYellowRedPulse OxHeart Rate (bpm)BP: SystolicBP: DiastolicTemperature (°F)Weight (CHF only)Blood Glucose (mg/dl)Peak FlowRespiratory RateOther: _________Other: _________Section 3: Escalation and Notification RulesThe BlueStar QHP will take actions based on patient condition, per the following:GreenYellowRedStatusNormalWatchAlertQHP ActionNoneContact the patientAssist patient in retake of the vital signs. Confirm readings.Ask the doctor-approved questionsNotify Practice per the chosen method belowNote in VitalCare recordContact the patientAssist patient in retake of the vital signs. Confirm readings.Ask the doctor-approved questionsNotify Practice per the chosen method belowNote in VitalCare recordNotification Method (mark choices)None[ ] DAILY REPORT: QHP will send a daily report via e-mail to the Practice with a list of all patients in a Yellow status.[ ] VITALCARE STATUS ALERTS: QHP will program alerts in VitalCare platform to automatically alert Practice staff through the software.[ ] PHONE CALL: QHP will contact the Practice staff by phone when QHP becomes aware of the abnormal reading (may be next day). [ ] E-MAIL: QHP will contact the Practice staff by e-mail or text.[ ] DAILY REPORT: QHP will send a daily report to the Practice with a list of all patients in a Red status[ ] VITALCARE STATUS ALERTS: QHP will program alerts in VitalCare platform to automatically alert Practice staff through the softwareAll escalation calls, notes, messages, and time will be accounted by the QHP in the VitalCare platform.Section 4: Doctor-Approved QuestionsUpon receipt of an abnormal value, the QHP will contact the patient and ask the following questions. Any unusual or alarming responses will be noted in the record, and may be cause for escalation per the rules above:General welfare:How are you feeling today?What were you doing before you took your vital signs?Have you been taking your medicine?Are you feeling fatigued?Are there any other symptoms you would like to let your doctor know about?Evidence of a Stoke:Any sudden numbness or weakness in your face, arm, leg, or one side of the body?Any sudden confusion, trouble speaking, or difficulty understand speech?Any sudden trouble seeing in one or both eyes?Any sudden trouble walking, dizziness, loss of balance, or lack of coordination?Any sudden severe headache with no known cause?Evidence of a Heart Attack:Uncomfortable pressure, squeezing, fullness, or pain in the center of the chest?Did the pain come on quickly and not go away with rest?Pain or discomfort in one or both arms, the back, neck, jaw, or stomach?Shortness of breath with or without chest discomfort?Breaking out in a cold sweat, with nausea or lightheadedness?Section 5: Rules for Calling 911When abnormal values are detected, BlueStar’s QHP will engage with the patient and ask questions per the above. When any of the following four conditions apply, the QHP will call 911 for help, and direct 911 to the address on file. While 911 is in progress, the QHP will stay on the line with the patient until help arrives. As soon as 911 support arrives, the QHP will immediately contact the Practice.Any of the following circumstances occur, the BlueStar QHP will call 911:If the patient reports symptoms of a Stroke, per the aboveIf the patient reports symptoms of a Heart Attack, per the aboveIf the patient reports that he/she is threatening harm to himself or herselfIf the patient or others report that the patient may cause harm to someone elseIf the patient requests 911 assistance from the QHPOnce emergency services have been notified, BlueStar cannot be held liable for the patient’s decisions or care. The patient is solely responsible for any expenses incurred for the use of emergency services.Section 6: Actions for Non-ComplianceIf a patient has not taken vitals or responded to surveys, BlueStar’s QHP will take the following actions, based on the number of days of non-compliance:StatusDays of Non-ComplianceActionsGreen1-2Send a message to the patient through the portal, reminding her to update her vital signs.Yellow3-5The QHP will:Call the patientText the patientSend a message through the portalNotify the doctor’s officeRed6 or moreIf the patient is non-compliant for more than 5 days, the BlueStar team will call the patient’s emergency contact number. If that is not successful, BlueStar will work with the doctor’s office to together find a way to reach the patient. ................
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