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Access to Care and Chronic Care Management

Jon-Michial Carter
Written by Jon-Michial Carter

According to the Center for Disease Control (CDC), six out of 10 Americans have a chronic illness. Four out of every 10 have two or more. However, many chronic illness patients are unable to access the care they need, which can have devastating consequences for their health. 

Implementing a Chronic Care Management (CCM) program in your practice can help improve access to care for patients with chronic conditions. 

Challenges in Accessing Chronic Care Management

Ideally, chronic disease management occurs in a practice care setting, where providers can closely monitor their patients and provide preventive care as needed. However, a patient's ability to access care depends heavily on a range of socio-economic factors known as the social determinants of health. The U.S. Department of Health's Healthy People 2030 lists the following as the top five contributing factors:

  1. A patient's economic stability
  2. Access to quality education
  3. Access to quality health care
  4. Neighborhood and built environment
  5. Social and community context

Out of these five, a patient's economic stability — specifically, lack of access to adequate health coverage — is the largest barrier to care access. According to the U.S. Department of Health, about one in every 10 Americans is uninsured. These individuals are less likely to have primary care providers, and they may be unable to afford care.

Having to pay for treatment out-of-pocket discourages many uninsured patients from seeking preventive treatment. 

Patients who experience economic instability also often lack access to reliable transportation, which can lead them to delay or cancel important appointments.

As a result, many patients seek emergency treatment for conditions that could have been mitigated. From 2017 to 2019, 61.5% of adult emergency department visits were made by patients with one or more chronic diseases.

Put simply, these factors significantly impact a patient's access to care, which can lead to preventable crises. While the emergency department (ED) is an inefficient place for chronically ill patients to receive care, it's often more convenient and accessible than scheduling regular appointments with a primary care provider, especially for uninsured patients. 

The importance of access to care is impossible to overstate. Chronic Care Management (CCM) programs provide lasting coverage to patients who have two or more chronic conditions, enabling them to maintain a strong relationship with their care team and improving their health outcomes. 

However, it is important to note that CCM is a preventative measure. It is not meant to replace regular office visits or visits to the emergency room. It can help prevent emergency room visits and helps the practice identify any gaps in care.  

How COVID-19 Is Changing Access to Health Care

The onset of COVID-19 radically changed the medical landscape in the U.S., including how providers and patients make health care decisions. 

For example, to avoid risking exposure to COVID-19, many patients rescheduled or canceled routine preventive appointments like annual wellness visits. Many providers also deferred these visits to reduce the risk of spreading the virus within their practices — as a result, many patients went without preventative care.

While the pandemic has highlighted the cracks in health care inequity, it has also sparked positive changes in access to care by prompting many practices to take steps toward a digital transformation. Telehealth, for example, has evolved from a temporary solution into an effective way to provide care to patients. 

Emerging technologies like artificial intelligence (AI) and machine learning (ML) are transforming health care as we know it by giving providers new, more effective ways to apply their clinical knowledge. As we progress past COVID-19, the industry is likely to shift its attention to exploring how AI/ML can offer the most value across a wide range of use cases, such as learning how to provide more personalized medical treatment.

Similarly, COVID-19 has also revealed the importance of Chronic Care Management programs for both practices and their patients. Even when patients are unable to make in-person visits, regular updates through a CCM program help keep them on track with preventative care. 

CCM programs also relieve some of the financial barriers to health care that patients experience. According to the national average for CCM programs, patients save approximately $74 per month in Medicare costs, making care significantly more affordable than it would be in practices without a CCM program. 

How to Improve Access for Your Patients With CCM 

When you implement a CCM program, you need to make it accessible for your eligible patients. And accessibility goes beyond cost — convenience and availability are also crucial contributing factors. 

Often, remote care is available at the provider's convenience rather than the patient's, which can be a barrier to patients who have busy schedules or need assistance after-hours. Providing a 24/7 support line — or extending your remote hours beyond regular office hours — makes it possible for many patients to receive the care they need when they need it. 

If patients have trouble finding the right specialists or doctors in their area, they're more likely to hesitate in seeking care. Make sure patients know where and how to access your clinic, including via telemedicine.

Use the Right Technology

Telehealth has been growing in popularity since the onset of COVID-19 — and for a good reason. It's reliable, quick and convenient for patients who may experience difficulties making it to face-to-face appointments. 

However, for many patients currently aging into Medicare, technology can be a barrier to receiving the proper care. That's why it's best to avoid overly complex apps and software platforms that could discourage patients from seeking help. 

Before you implement any telemedicine solution, do your research. Make sure your solution is user-friendly and easy for users to figure out. Even better, choose a solution that includes reaching out to your patients in addition to providing a support line for them to use. This way, your staff can more easily keep tabs on patients' conditions while opening a channel of communication.

Additionally, investing in a CCM solution is an excellent way to ensure your patients are getting the care they need between visits. While CCM check-ins are different from telemedicine appointments, a good CCM program will include multiple modes of communication to get in touch with your patients, including phone calls, SMS texting, direct mail, and email. 

Delight Your Patients

Whether you're creating an in-house CCM program or partnering with a trusted CCM service, your focus should be on creating a welcoming, supportive patient experience. 

Providing assistance with the following can enhance the patient experience:

  • Regular check-ins: Conducting remote check-ins with your patients at times that suit their schedules is a great way to ensure you're meeting their needs. 
  • Education: Patients need sufficient information about your CCM program's benefits to develop a thorough understanding of how it can help them properly manage their conditions. Sending marketing collateral and providing open channels of communication is a great way to improve your patients' access to information.
  • Online presence: Your practice's online presence will help prospective patients understand what to expect from you. Be sure to offer detailed information on your website about how to contact you so patients can reach out.
  • Medication refills: Sometimes, patients cannot access the medications they need due to insurance barriers or confusing red tape. Assisting your patients with obtaining prescription refills can help ensure they have what they need to successfully manage their health.

Work With a Fully Managed CCM Provider

ChartSpan is the largest CCM managed service provider in the country. Our turnkey care coordination program helps health care providers effectively coordinate care to improve patient outcomes and increase access to quality care while simultaneously increasing practice revenue. 

We strive to improve health outcomes by increasing engagement between providers and patients. When you choose to implement a CCM program with ChartSpan, we'll take the workload off your staff's shoulders so you can focus on the everyday responsibilities of running your clinic. 

Most practices that attempt to implement an in-house CCM program only manage to enroll about 10% of their eligible patients. However, when you partner with a CCM provider, your enrollment rate will increase significantly due to the resources, technologies and processes they use. On average, ChartSpan averages an over 60% enrollment rate in the clinics we work with. 

ChartSpan provides end-to-end support for many types of practices, from primary care providers, specialties, FQHCs and RHCs — we handle the CCM process from start to finish so you can tend to your patients without interruption to your daily workflows. 


Contact ChartSpan for More Information

Partnering with ChartSpan opens access to Chronic Care Management for all your eligible patients. Our expert care staff will become an extension of your care coordination team so your patients with chronic conditions have access to clinicians whenever they need it. 

Make high-quality health care more accessible to your patients. Contact us today for more information about our chronic care management services.

Empower your providers and delight your patients!

Proactively address patient health with preventive care programs that provide more revenue for your practice and more personalized care for your patients.

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