Virtual Care

The basis of the Soteria-360 program is building a set of data points through RPM & CCM to enable the most effective care possible. If the physician team has other data points they would like to integrate, we can work with you and the third-party provider to implement these metrics.

The SilveRise at Home Soteria program offers virtual telehealth care on the patient's TV in the privacy of their home, Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) services to help monitor vital signs, chronic conditions, medication adherence, nutrition, and exercise. ​    

SilveRise at Home Program

1.  Physician Practice will schedule an appointment with the patient for the initial virtual care visit.  The purpose of the visit is to establish care with the patient.

2. Physician/NPP is to conduct a Medication Reconciliation prior to or the day of the initial visit (Med Rec is to be done by a physician, NPP or RN). 

3. It is recommended for the physician/designated physician staff to remind the patient of the visit and assure readiness for the call.

4.  Physician/NPP will  schedule  Monthly Virtual Care Follow-up Visits for coordination of care and teaching per the patient plan of care. (Refer to CPT Codes and Descriptions).

5. If the physician care team thinks the patient would benefit from medication management and the patient is eligible, Physician/NPP to discuss the need for Medication Management GTI labs with the patient as indicated.  Educate the patient on the process for gathering specimens, and notify GTI to request lab.  Please see the Medication Management Guide on the Guidelines and Resources tab.

6. Physician/NPP may schedule medication reminders in the virtual care system or other reminders or messages and schedule other Post Discharge Telehealth Consults PRN.

7. Physician/NPP may provide communication with the Primary Care Physician and assist with the coordination of care as needed.

8. Physician/NPP to discuss and provide patient/caregiver information on Chronic Care Management Program with patient/caregiver. 

9. Physician/NPP to schedule Monthly  Virtual Care Follow-up Visits for coordination of care, assessment, and teaching per the patient plan of care.  

10. As needed, or PRN Virtual Visits may be scheduled as well.  An example would be to follow-up with a virtual visit when the patient has a fall or calls 911 using their PERS device.

11. RPM Care Team will continue to provide check-in visits with the patient/caregiver as needed throughout the program and as your care team directs. 

Medication Management

1. What is the test? 

This is a simple urine test that uses the same science as toxicology. It is designed to confirm that patients with chronic disease (hypertension, diabetes, kidney disease) are taking their maintenance medications (Lisinopril, Metformin, Plavix) 

2. Why order the test? 

   • To ensure that patients are taking their prescribed maintenance medications 

   • To determine if patients are metabolizing their medications appropriately 

   • Increase patient compliance 

3. When should this test be done? 

   • New Patient 

   • Hospital Follow up 

   • Post Medication changes 

4. What happens in cases of abnormal results?

The clinical team reviews all abnormal reports, and if critical (anticoagulant missing) will call the provider/clinic/rep ASAP 

5. Is this covered by Medicare/Commercial/Medicaid?

   • Medicare: Covers 100% of this test 

   • Commercial: Insurance will cover the test (patient responsible for the deductible, if applicable) 

   • Medicaid: May be covered depending on the state 

6. How often can this test be performed? 

This test can be performed every 30 days, though most are collected every 2-3 months per patient and can always be collected after a hospital stay.  

7. What if medication(s) are not in the patient’s specimen? 

There are two reasons:

7. • 1. The patient is not metabolizing the medication appropriately (Biological)  

     2. The patient is not taking the medication (Behavioral) 

What else should we know about the Remote Patient Monitoring Team?

• The PERS device monitoring team monitors the PERS device around the clock and responds when the patient/caregiver activates the device for emergency assistance.

• The cellular RPM devices transmit vital sign information to the dashboard when the patient or caregiver takes the reading.  Pre-programmed parameters within the system trigger automatic alerts per the Alert Protocol, or as you prescribe.

• The RPM Care Team provides additional monitoring support and response to technical and care alerts, Monday through Friday during regular business hours.

• The Soteria Program Liaison provides patient/caregiver support with RPM, PERS devices and resolving technical alerts when notified of issues.

• The Physician can monitor patient vital signs through the Soteria Dashboard.

Role of your Program Liaison

• Coordinate communication between Odessa, 1bios, and Physician practice to provide better outcomes for the program and better experiences to your clients​

• Perform client contact via virtual calls, phone calls, and emails to patients to provide troubleshooting and resolve issues and concerns with Odessa and RPM devices​

• Perform test calls upon installation of OdessaConnect and prior to Physician practice visits to ensure a better virtual experience for both the Physician practice and our clients​

• Provide technical assistance with regard to RPM devices to patients and family members who are involved in the program​​

• Ensure confidentiality of clients' information and health status.​

• Perform other tasks and duties as assigned

Clinical Notes

Clinical Notes are a crucial element of the Sotera-360 program. For each note, the following information will be collected:

• Date of note

• Consent for telehealth virtual visit - Yes/No

• Virtual visit note (visit conducted through video call) - Yes/No

• Facility course of care (reason the patient was receiving medical treatment)

• Patient location (during the consultation)

• Another individual present during contact - Yes/No

  • Name of the individual present with the patient

  • Relation to patient

• History of present illness, chief complaint

• CPT Code

• Diagnosis ICD-10 Codes

• Completed medical reconciliation - Yes/No 

• Changes to patient medication

• Summary of virtual visit (includes review of systems, vital signs, labs, referrals needed, and/or coordination of care)

• Patient education

• Plan of care

• Date set for next encounter