Chronic Care Staffing provides our clinical services of Chronic Care Management, Behavioral Health Integration, and Annual Wellness Visits for the following clients:
Primary Care and Internal Medicine providers face unique challenges of delivering Medicare’s Care Management Services in an office setting with limited staff resources. CCS offers increased efficiency
Federal Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)
FQHCs and RHCs have some of the highest at risk patient populations among health institutions in the United States. CCM, BHI, and AWV have significantly helped reduce gaps in care while focusing on such issues as Social Determinants of Health.
Medicare’s care management services are an excellent way to manage patients that are attributed to a hospital system and their providers by reducing ER visits and readmissions to the hospital.
Accountable Care Organizations (ACOs)
Chronic Care Management, Behavioral Health Integration, and Annual Wellness Visits are the foundation of improving the ACOs quality metrics and outcome measures. Here are the areas that Chronic Care Staffing’s Care Management Services increase ACOs overall impact:
- Risk Assessment Factor (RAF) score. Looking at the ACO quality measures for the RAF scores CCM can/do help positively impact the following with what we have incorporated into our monthly calls:
- At risk population- Diabetes, Hypertension, CAD- patients with poor control and elevated HGA1C >8/>9 categories, LDL, BP, Tobacco non use: We provide education on chronic condition control and self-management techniques, we look for compliance with medication regimens, appointment follow-ups, and laboratory follow-ups, etc. We remind patients that may not be completely compliant or may be overdue to follow up with their providers and assist with making appointments.
- Hospital utilization.- Starts with increasing the patient’s awareness and knowledge of their chronic conditions and how to better self manage their conditions assists with decreasing hospital/er utilizations. We also educate the patients to call either us or their providers with any change in the condition in order to get them back into the office for a checkup to reduce the chances of being hospitalized. We have seen first hand how our calls have impacted this by way of when we are discussing the patient conditions and current status we have the ability to recognize acute changes and assist the patient in making an appointment with their provider.
- Preventing Readmissions via better care transitions- Care transitions are when the patient is most at risk for recidivism. We have been able to identify patients that have been hospitalized even before the providers are aware. We perform medication reconciliations, discuss the reason for the hospitalization, provide education, and assist with getting the patient back into the provider office for a follow-up. Additionally, we place these patients on an every 2 week follow up call to check in on their health status.
- Active management of high need/high-cost patients- With each monthly CCM call, we are performing in-depth chart reviews and holding conversations with the patients discussing their chronic conditions. Again, we are increasing their awareness of and knowledge of their chronic conditions and offering education on how to better self manage. We are looking at labs, meds, referrals, office visits, and diagnostics with the goal of closing any gaps in care and keeping the patient and provider well informed.
- Manage/reduce post-acute care spending- This is achievable with managing transitions of care
- Increase referrals to ACO based providers/reducing leakage – This keeps patients attributed to the ACO under the same umbrella of care when they see specialists.
- Integrate behavioral health care into primary care settings- This is achievable by using the Behavioral Health Integration program so that patients with these diagnoses more closely monitored.
- Medicare Shared Savings Program (MSSP)
- Social Determinants of Health (SDoH)
Specialists such as but not limited to Cardiologists, Nephrologists, and Neurology can enroll patients in Chronic Care Management as many of their patients have several chronic conditions in their related fields.
Commercial/Private Insurance Carriers
Chronic Care Staffing can perform the same Care Management Services for commercial/private insurance patients as it does for it’s Medicare and Medicare Advantage patients. We partner with these clients to improve their patients health outcomes while reducing costs for the insurance company. A segment of our Care Coordinator staff have been previously employed by Commercial/Private Insurance Carriers to perform case management services for their patients.