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CCM Services and Healthcare Accessibility

Jon-Michial Carter
Written by Jon-Michial Carter

A patient’s ability to receive preventative healthcare depends on multiple factors: cost, access to transportation, time to attend appointments, and the ability to receive information in a way they understand.

Chronic Care Management (CCM) services can’t remove all the barriers to healthcare accessibility. But for Medicare patients who already see at least one provider and have more than one chronic condition, CCM can:

  • Reduce expensive emergency room and urgent care visits
  • Provide patients with care at convenient times
  • Give patients healthcare guidance at home
  • Offer resources like transportation services
  • Answer questions and share information in understandable language

Here are just a few services CCM can offer to make healthcare more accessible to your practice’s patients. 

1. Reduce Healthcare Costs for Patients

Economic stability is one of the social determinants of health that most dramatically impacts people’s ability to receive care. 

Even people who have insurance, like people on Medicare, often have medical debt, and out-of-pocket costs can lead them to delay doctors’ visits or prescription refills.

Chronic Care Management has a copay for many patients. However, the cost is much less than having a full doctor’s appointment every month, and the preventative care provided by CCM can help patients avoid unnecessary emergency department visits. Medicare claims data show that CCM reduces avoidable hospital visits by at least 4.7% and ED visits by 2.3%

Another way to help decrease costs is through medications. CCM care coordinators can help patients find affordable ways to refill needed medicines. A care coordinator might direct patients to prescription discount programs or compare prices between different pharmacies and let the patient know which one is least expensive. 

2. Give Patients Access to Care 24/7

Chronic Care Management can also help with another Social Determinant of Health that impacts patient outcomes, Health Care Access and Quality. Even patients who have health insurance and who can afford copays might have trouble accessing care if they work strict hours or live a long distance from the nearest practice. 

These problems are especially pressing for patients at Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs.) Patients at FQHCs often have hourly jobs or lack transportation, and patients at Rural Health Clinics also struggle with living long distances from healthcare. This is why CMS agreed to reimburse CCM at higher rates for these organizations. 

Many healthcare practices are only open during typical business hours. People who can’t leave work are therefore forced to go to expensive urgent care clinics or the emergency department, even for conditions that aren’t necessarily emergencies. 

Chronic Care Management can alleviate this problem. Medicare requires CCM to include 24/7 access to care, and ChartSpan addresses this need with a 24-hour nurse line staffed by RNs and LPNs. Patients can call the line anytime they start experiencing symptoms, and a licensed nurse will determine what they should do and whether they need to visit urgent care or the ED.

Access to a nurse line reduces unnecessary ED visits and gives patients the security of knowing they can always reach a medical professional. 

3. Provide Preventative Care Remotely

Patients will always need to visit a practice or hospital for some forms of care. But people who have disabilities, don’t have access to transportation, care for children, or work strict hours might find it difficult to leave their homes for preventative care every month. 

Chronic Care Management addresses this challenge by giving patients monthly care through phone calls or online patient portals. 

With CCM, patients receive 20 minutes of remote care every month. They can speak on the phone with their care coordinator about their care goals and the progress they’re making with nutrition, quitting tobacco, or exercise. 

If they’re not able to answer the phone, they can visit their online patient portal to see updates to their care plan and to download resources, like tips for managing their conditions or healthy recipes. 

4. Give Patients Consistent Access to Care

CMS requires that CCM “provide patients and caregivers enhanced opportunities to communicate with their practitioners about their care by phone and through secure messaging, secure web, or other asynchronous non-face-to-face consultation methods (like email or secure electronic patient portal.)”

Many CMS vendors, ChartSpan included, meet this requirement by combining a 24-hour nurse line with a secure electronic patient portal. But some vendors also offer other methods for patients to communicate with their care coordinators.

ChartSpan gives patients the opportunity to reach out to their care coordinator via email and text, as well as by phone call. If the patient needs to speak to a healthcare professional before their coordinator has a chance to respond, they can call the nurse line.

5. Assist with Transportation

In addition to offering care at home, care managers can arrange transportation to appointments for patients who don’t have their own vehicles or can’t drive. 

Patients in rural locations often have to travel long distances to a clinic because of a lack of physicians. In fact, the patient-to-primary care physician ratio in rural locations is 39.8 physicians per 100,000 people, compared to 53.3 physicians to every 100,000 in urban areas. Because of this, rural patients frequently struggle to reach care

If a care manager hears that a patient is having trouble seeing their provider, they can connect the patient with transportation services, like taxi or rideshare companies. These services are often covered by Medicare when used for provider appointments. 

Transportation services can even be helpful for people who live in urban areas if they don’t have access to a car, have disabilities, or don’t live near reliable public transportation. No matter why the patient struggles to reach their appointments, CCM coordinators can connect them to transportation. 

6. Offer Culturally Conscious Care

People who don’t speak the majority language of the country they live in are at greater risk of adverse health effects and challenges in accessing high-quality care. In the U.S., about 67 million people speak a language other than English at home. 

Some providers who don’t speak the same language as their patients use translators, while others rely on written materials or ask patients to bring family members who can translate. 

But even with these accommodations, patients who aren’t fluent in English are less likely to receive information about health maintenance and promotion, healthy aging, and activities of daily living during visits with their providers. They are also less likely to have their psychosocial needs addressed. 

CCM can help fill in these gaps. Chronic Care Management was specifically designed to address concerns like health maintenance, daily living activities, and social needs. Many CCM vendors also offer detailed printed materials or online care plans in multiple languages, and some vendors can provide care managers who speak multiple languages. 

Increasing Accessibility with CCM Services

Patients with multiple chronic conditions often have trouble accessing care. Some can’t afford to visit a practice or clinic, especially if they need care after typical business hours. Others have difficulty reaching appointments because they lack transportation, have to work, or live with disabilities. And still others struggle to find care in their preferred language. 

Chronic Care Management can’t eliminate these challenges, but it can help make healthcare more accessible. CCM vendors, like ChartSpan, can offer 24/7 nurse lines, preventative care at home, access to transportation services, and care in multiple languages. 

Want to learn more about how CCM makes healthcare accessible? Check out our case study with Ryan Health, a Federally Qualified Health Center that cares for many historically underserved patients.

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