Chronic Care Management: Our Unique Approach to Enhancing Patient Care

Story by CCS Editor / July 12, 2024

Chronic Care Management (CCM) is a lifeline for patients with multiple chronic conditions, offering essential care coordination and support. Launched by Medicare in 2015, the same year Chronic Care Staffing (CCS) was founded, CCM aims to improve patient outcomes and streamline care for those with chronic illnesses. Our distinctive take on CCM focuses on clinically driven, patient-centered care, with no software integration required, zero upfront costs, and fully customizable solutions. Let’s dive into what makes our approach special and how it can benefit both patients and practices.

What is Chronic Care Management?

Chronic Care Management (CCM) is a program designed for Medicare and Medicare Advantage patients who have two or more chronic conditions expected to last at least 12 months. The program is billed under code G0511 for FQHCs and 99490 for private practices, providing practices with reimbursement for 20 minutes of monthly care coordination per patient. Here’s what that looks like:

• Chart review: We identify any changes in condition, prior and upcoming appointments, and outstanding medication refills or referrals.
• Phone calls: We require that each patient is spoken to in order to bill for the service every month. Our monthly focus varies to match the initiatives your practice is prioritizing.
• Follow-up: We chart each encounter in real-time directly in your EMR and relay any necessary information back to the provider.

Benefits of CCM

Implementing a CCM program brings numerous benefits for both patients and practices:

• Better care coordination: Patients enjoy improved satisfaction and outcomes through consistent monitoring and support.
• Higher quality measures: Practices meet and often exceed healthcare quality standards.
• Increased revenue: A steady revenue stream is generated through regular billing of CCM services.
• More efficient use of staff time: Practice staff can focus more on direct patient care in the office.
• Fewer emergency visits: Proactive management of patient health reduces unnecessary ER visits and hospitalizations.

Our Unique Approach to CCM

We take pride in our unique, clinically driven approach to CCM. Here’s what sets us apart:

1. Clinically Based Virtual Care
   Unlike software-based CCM programs, we prioritize patient care over technology. All our resources are dedicated to ensuring each patient interaction is meaningful and impactful. Our care coordinators, who are Licensed Practical Nurses (LPN) or Certified Medical Assistants (CMA), are trained to engage with patients effectively and address their unique needs.
2. White-Labeled Delivery
   Our programs are tailored to your practice’s needs. We identify as your practice and chart directly in your Electronic Medical Record (EMR) system, ensuring seamless integration and real-time communication without requiring additional software or integration costs.
3. No Upfront Costs
   We believe that high-quality care should be accessible to all practices, regardless of their financial situation. Therefore, we offer zero upfront costs. We bill you only if the patient is spoken to during their monthly encounter.
4. Customizable Workflow
   Every practice is unique, and so are their patients. Our CCM programs are fully customizable to align with your existing workflows and patient care protocols. This flexibility allows for easy implementation and scalability, maximizing both financial impact and patient engagement.

Real-World Success Stories

Our CCM program has made a real difference in the lives of patients and the efficiency of practices. For example, at a Federally Qualified Health Center (FQHC) in Tennessee, diabetic patients enrolled in our CCM program saw their average HbA1C levels drop from 9.7 in 2022 to 8.3 in 2023. Similarly, an FQHC in Charleston improved its Medication Adherence Star Rating from 3.53 in 2019 to 4.20 in 2020, thanks to our patient education and support efforts.

Quality Assurance and IT Security

We are committed to maintaining the highest standards of quality and security. Our ongoing quality assurance processes ensure that care is consistently delivered according to CMS guidelines and our rigorous clinical standards. We use HIPAA-compliant systems for recording and transcribing patient calls, and our IT infrastructure supports seamless operation within any EHR and remote desktop/VPN setup.

High Quality Care for our Patients

Chronic Care Management is a crucial service that enhances patient care, improves health outcomes, and boosts practice revenue. Our unique, clinically driven approach ensures that patient care is prioritized, with no software constraints, zero upfront costs, and fully customizable solutions tailored to each practice’s needs. By partnering with us, you can maximize the benefits of CCM, providing high-quality care to your patients while achieving your financial goals. If you’re interested in learning more about how our CCM program can benefit your practice, please contact us today.

Categories: Chronic Care Management News