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CCM for cardiology: your guide to Chronic Care Management

Jon-Michial Carter
Written by Jon-Michial Carter

75% of U.S. residents over the age of 60 live with cardiovascular disease, including chronic conditions like hypertension, hyperlipidemia, and congestive heart failure. 

Medicare’s Chronic Care Management (CCM) program is specifically designed to help patients better manage ongoing conditions. And because so many chronic conditions are closely tied to heart health, Medicare reimburses cardiology practices that offer CCM. 

CCM gives patients the opportunity to improve their quality of life and perhaps even slow their disease progression. In turn, cardiology practices can benefit from increased revenue and more regular contact with the patients they serve. Check out these seven reasons your cardiology practice may want to consider Chronic Care Management. 

CCM addresses common cardiovascular conditions

ChartSpan and other CCM companies have helped patients with a wide range of heart conditions, including: 

  • Coronary heart disease
  • Atrial fibrillation
  • Sick sinus syndrome
  • Congestive heart failure
  • Angina pectoris

CCM can also help patients with conditions closely connected to heart disease, such as hypertension, hyperlipidemia, and diabetes. Because so many cardiovascular conditions qualify for CCM, a variety of cardiology patients can benefit from the program. 

Patients receive a comprehensive care plan

When a cardiology patient enrolls in CCM, their care coordinator will help them create a comprehensive care plan. This plan includes specific, achievable goals to help patients improve their heart health and quality of life. Examples of care goals are: 

  • Beginning to exercise 2 or 3x a week
  • Preparing healthy meals at home
  • Quitting smoking
  • Reducing alcohol consumption
  • Engaging with local organizations, like exercise groups or fresh food markets

At ChartSpan, a Registered Nurse or Licensed Practical Nurse oversees every care plan. Our nurses also work closely with providers to ensure patient care plans align with their recommendations. 

Why are care plans such an important part of preventative care? Patients with a CCM care plan have lower rates of emergency room visits and hospitalization. Care plans can also give patients the power to improve their own health–which can be life-changing for patients with serious cardiovascular conditions. 

CCM empowers patients to take charge of their health

Living with a heart condition can be frightening and stressful. But Chronic Care Management can help patients regain a sense of control and self-efficacy.

CCM coordinators provide collateral and one-on-one conversations to help patients better understand their conditions and symptoms. Patients also have ongoing access to their care plan, so they always know which health goals they’re working toward.

Every month, the patient will receive a call from their care coordinator, who can review their goals, congratulate them on the ones they’ve reached, and provide encouragement for the ones they’re still working on. 

If patients start to experience new symptoms, they also have the security of knowing they can reach a medical professional at any time, even when their provider’s office is closed. 

Cardiology patients have access to a 24/7 nurse line

Medicare requires Chronic Care Management programs to include a 24-hour nurse line. If patients start experiencing symptoms when their provider’s office is closed, they can call the nurse line to share their concerns and receive a professional opinion on whether they need to go to urgent care or the emergency room.

A nurse line can reduce unnecessary emergency room visits. But more importantly, it gives patients a sense of security. 

Through CCM, cardiology patients know they always have access to healthcare professionals who can answer their questions about blood pressure, glucose readings, or unexpected pain: even in the middle of the night, on weekends, or on holidays. 

CCM can address social determinants of health

Social determinants of health (SDOH), like access to healthy food, safe housing, transportation, and affordable healthcare, can affect people’s risk of developing cardiovascular conditions like high blood pressure, diabetes, and high cholesterol. 

SDOH also impacts people’s ability to manage these conditions. It’s hard to exercise if you live in an unsafe area for pedestrians or can’t afford a gym membership. Food deserts and limited budgets make it difficult to access fresh vegetables and fruit, and people who are worried about financial stability often face tremendous stress and have trouble getting enough sleep. 

Because CCM coordinators check in with patients every month, they can quickly find out what SDOH support patients need. The CCM team can then provide contact information for food pantries and fresh food markets, housing agencies, car services, and other vital resources to help patients manage their health. 

At one cardiology practice, ChartSpan managed to provide 300% of patients with SDOH support: the number reached 300% because so many patients received support more than once. 

Cardiology practices spend less time on administrative tasks

Refill requests, appointment scheduling, and other administrative requests can overwhelm smaller practices with limited staff. A good CCM partner will help patients with appointments or refills, while following the practice’s preferences. 

In the past, the ChartSpan clinical team has called the pharmacy directly for refills, reached out to providers’ offices, or helped patients contact pharmacies, all based on what the practice asked us to do. Similarly, some practices have allowed us to schedule appointments for patients, while others want us to direct the patient to call them. 

By working with a CCM partner, you can give your patients greater flexibility in how they schedule appointments or request refills, without forcing your staff to spend all day on the phone. 

Practices can increase their revenue without overworking staff

Chronic Care Management offers a new stream of monthly recurring revenue for practices. And with a CCM partner, your cardiology practice can receive this extra revenue without straining your existing staff. 

One small, independent cardiology practice partnered with ChartSpan for CCM and generated $57,000 in additional annual revenue. In a single year, the ChartSpan team managed 2,000+ outbound calls, 500+ inbound calls, and 300+ SDOH-related calls.

Independent or smaller practices rarely have enough staff to manage that volume of CCM calls on their own. But the practice managed them successfully–and earned more revenue–with ChartSpan’s assistance.

Chronic Care Management and cardiology

Care plans, patient empowerment, Social Determinants of Health, and a 24/7 nurse line can help all people with chronic conditions. But these resources are critical for patients with cardiovascular disease, who can substantially improve their health outcomes with lifestyle changes and ongoing support from their cardiology provider.

Want to learn more about how CCM can help you care for your patients while increasing your practice’s revenue? Check out our Chronic Care Management for Cardiology hub, which includes additional information and a free download.

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