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How a Nurses-First Model Ensures Chronic Care Management Success

Written by Jon-Michial Carter

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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 licensed nurse overseeing clinical protocols, 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 licensed nurse oversees protocols used by clinical staff for patients. A nurse-led program helps drive better patient outcomes, patient retention, and oversight of clinical staff. Nurses are extremely effective at managing the needs of chronically ill patients because of their clinical skillset.

At ChartSpan, dedicated nurses and clinicians 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 and clinicians 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. 

Nurses First also means that licensed RNs manage all high-acuity events. If a patient calls the 24-hour nurse line with a medical concern that is considered high-acuity, an RN will handle the call and use Schmitt-Thompson triage protocols.

Who can make Chronic Care Management calls? 

Chronic Care Management can be performed under general supervision of the billing provider. 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, 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 or clinician 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 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 or Clinician 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 nurse or clinician care manager is unable to reach a patient in the given month, other activities can be performed to meet the 20 minutes of required 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 Assistants (CNA), Registered Nurses (RN), and other nurses can work as Chronic Care Managers. In some states, medical assistants or other clinical support staff can also work as care coordinators. Working as a chronic care nurse is a popular choice for nurses and clinical staff 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. 

Learn More About Nurses First and Chronic Care Management

Chronic Care Management ensures patients have a nurse or clinician to assist with care plans, care goals, and educational resources. If you’d like to learn more about the roles nurses and clinicians play in Chronic Care Management, you can visit Care Management Explained: Services & Significance for Your Medical Practice.