How a Nurses-First Model Ensures Chronic Care Management Success

One of the most commonly asked questions about running a Chronic Care Management program is, “Who can perform Chronic Care Management services?” In other words, “Who exactly is taking care of my patients?” This is a frequent hesitation for healthcare organizations considering an outside CCM partner. If you are going to be handing over the care of your patients to another party, there has to be a high level of trust involved. That’s why it’s important to have a certified nurse leading the care of your patients, like in ChartSpan’s Nurses-First staffing model. 

What is a Nurses-First model for Chronic Care Management? 

In a Nurses-First CCM model, a nurse leads the care of patients. A nurse-led program helps drive better patient outcomes, patient retention, and oversight of lower-level clinical staff. Nurses are extremely effective at managing the needs of chronically ill patients because of their clinical skillset. Unlike third parties who use contracted nurses, every ChartSpan nurse is an employee. 

At ChartSpan, dedicated nurses are assigned to specific practices and patients. In addition, clinicians and patients are matched regionally, providing better rapport with patients and faster resolutions to escalated clinical needs. This ensures a more personal patient approach, improved quality of care, and adherence to practice preferences. 

Each month, ChartSpan nurses provide clinical support for patients and build upon care goals and assessments. Care goals are aligned to specific chronic conditions and customized to each patient’s individual needs. 

Who can make Chronic Care Management calls? 

Chronic Care Management can be performed under general supervision of the billing provider if the patient has been seen within the past 12 months. CMS guidelines state a variety of physicians and non-physician providers can perform CCM services, including but not limited to: 

  • Physician Assistants 
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Nurse-Midwives

While clinicians, health coaches, nurses, and more can perform general CCM functions, all medical decision-making is left up to the provider. 

What does a Chronic Care Management Nurse do? 

A Chronic Care Manager nurse is responsible for a variety of activities to help Chronic Care Management patients manage their chronic conditions. 

Medicare’s non-complex Chronic Care Management program requires a minimum of 20 minutes of clinical staff time devoted to each patient, per month. The ideal goal is to have a portion of this time spent on the phone with the patient. However, patients do not always answer the phone.

If the Nurse Care Manager is able to reach the patient on the phone, they may engage the patient in:

  • Education about managing their chronic condition(s)
  • Reviewing symptoms and medications
  • Answering questions about their health
  • Performing health assessments
  • Setting and driving personalized care goals

When a care manager is unable to reach a patient in the given month, other activities can be performed to meet the 20 minutes of required staff time. These include but are not limited to: 

  • Care goal documentation
  • Refill and record requests
  • Care coordination between providers
  • Coordinating support services for social determinants of health
  • Electronic communication (email & SMS)
  • Setting appointments

Can an LPN do Chronic Care Management? 

Licensed Practical Nurses (LPN), Certified Nursing Assistant (CNA), Registered Nurse (RN), and other nurses can work as Chronic Care Managers. Working as a chronic care nurse is a popular choice for nurses who would like to work remotely from the comfort of their homes. The role offers more flexibility and work-life balance as it is a less demanding way to put nursing skills to use. 

Check out our job listings for Chronic Care Management work-from-home jobs.

Jon-Michial Carter is the Co-founder and Chief Growth Officer of the largest managed Chronic Care Management (CCM) company in the United States,...

Published: January 11, 2023

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