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 for your in-house staff to direct their attention on patients face to face and allows them to prioritize their time more efficiently.
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 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 cessation: 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 maybe 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 diagnoses. This patient education will assist in decreasing hospital/ER utilizations. We also educate the patients to either call their care coordinator or their provider’s office with any change in condition in order to get them scheduled for a checkup to reduce the chances of being hospitalized. We have seen firsthand how our calls have impacted this by 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 in post-hospital appointments with their provider. Additionally, we place these patients on an every 2-week follow-up call to check 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 and knowledge of their chronic conditions and offering education on how to better self-manage. We are reviewing labs, medications, referrals, office visits, and diagnostics with the goal of closing any gaps in care and keeping the patient and provider well informed.
Manage and reduce post-acute care spending which is achievable with our experienced care coordinators 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 are more closely monitored.
Medicare Shared Savings Program (MSSP)
Social Determinants of Health (SDoH)
Specialists such as but not limited to Cardiologists, Nephrologists, and Neurologists 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 its Medicare and Medicare Advantage patients. We partner with these clients to improve their patient’s health outcomes while reducing costs for the insurance company. A segment of our Care Coordinator staff has been previously employed by Commercial/Private Insurance Carriers to perform case management services for their patients.