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How CCM Benefits Chronic Kidney Disease Patients

Jon-Michial Carter
Written by Jon-Michial Carter

Chronic Kidney Disease (CKD) impacts nearly 37 million people in the U.S., including many Medicare patients who are eligible for Chronic Care Management (CCM). Thousands of primary care providers have already embraced CCM. But Medicare also allows some specialty practices to provide CCM, including nephrology practices.

Many patients with Chronic Kidney Disease see their nephrologist more than their Primary Care Provider, so it makes sense for their nephrologist to arrange additional care between visits. Addressing CKD on a regular basis can reduce the risk of complications to the patient’s overall health, like cardiovascular disease, hyperlipidemia and anemia.

Through CCM, you can help your nephrology patients establish a kidney-friendly diet, exercise safely, and perhaps even delay dialysis. At the same time, your practice will benefit from an additional stream of Medicare revenue. 

Check out ChartSpan’s guide to Chronic Care Management to learn more about how this value-based care program works, and continue reading to discover the benefits of CCM for your nephrology practice. 

1. Give patients access to nurses 24/7

ChartSpan’s Chronic Care Management gives patients the ability to reach a Registered Nurse (RN) or Licensed Practical Nurse (LPN) any time of day. Easy access to nurses is essential for patients with CKD, who often have coexisting conditions like hypertension, type II diabetes, and lupus in addition to kidney disease. 

Patients can speak to a nurse whenever they experience symptoms, even in the middle of the night. The nurse can then determine whether the patient should visit urgent care or the emergency room and call for emergency assistance if needed.

2. Build a personalized care plan for each patient

CCM services include a personalized care plan for every patient. These plans are especially valuable for Chronic Kidney Disease patients, who often have highly specific health needs. 

For example, providers now think it’s safe for most CKD patients to exercise, but their providers need to recommend how often and how vigorously. When a patient has an approved exercise plan, their CCM team can incorporate it into their overall care plan and ask the patient about exercise each month. 

Care coordinators can also help CKD patients set goals and work toward managing their other chronic conditions, like hypertension, cardiovascular disease or hyperlipidemia. With permission, care coordinators can access patients’ primary and specialty care records and see all of the conditions they’re currently living with. They can then make sure a patient’s chosen care goals align with advice from all of their providers, for all of their conditions.

CCM teams will also share the updated care plan with the provider offering CCM, so you can access it at any time and ensure it aligns with your goals for the patient. 

3. Help nephrology patients manage their diet

Patients with Chronic Kidney Disease frequently need to reduce how much salt, fat, and protein they consume. CCM care managers can provide dietary tips and healthy recipes for patients and check in every month on whether patients are following those guidelines.

ChartSpan care managers have:

  • Taught patients how to check food labels for sodium
  • Encouraged patients to eat small amounts of protein to reduce the burden on their kidneys
  • Provided recipes that include grilling, roasting, or baking instead of frying
  • Helped patients switch to vegetable oils instead of butter
  • Shared tips for eating more legumes, fruits, vegetables, and fish

Through these strategies, CCM can help patients take control of their nutrition and their kidney health.

4. Assist with medication management and refills

Many CKD patients take multiple medications to manage high blood pressure, diabetes, heart disease, or autoimmune diseases. Chronic Care Management can make remembering to take and refill medications easier. 

During monthly check-ins, care managers can ask patients if they take all their medications regularly. If they don’t, the care manager can help them set up phone reminders or daily pill containers. 

Patients can also call the 24/7 nurse line when they need a medication refill. Different CCM providers handle medication refills differently. ChartSpan’s approach is to follow practice preferences, whether that means calling the pharmacy directly, reaching out to the provider, or walking the patient through how to contact either one. 

5. Strengthen communication between providers and patients

Chronic Care Management also helps patients communicate with their providers more frequently. Suppose a CCM patient needs to set up an appointment with their nephrologist. Their care manager can set up the appointment directly or walk the patient through scheduling it, according to the provider’s preference. 

Many nephrology patients also have multiple healthcare providers, and CCM can help your practice stay in contact with them so you can make data-driven decisions. ChartSpan requests patients’ records from their primary care providers and any other specialists as often as you or the patient prefer, and we share those records with you.

Once you have the patient’s records, your nephrologists can examine the treatment patients are receiving from all of their providers to ensure there are no contradictory instructions or medication interactions that could lead to complications. They can thus ensure patients are receiving the best possible care to slow the progression of their Chronic Kidney Disease. 

6. Generate revenue for nephrology practices

Your nephrology practice must generate revenue to offer patients the best care for Chronic Kidney Disease. Chronic Care Management can help. 

One of ChartSpan’s nephrology clients is projected to bring in $690,000+ in additional annual revenue simply by adding a CCM program. A smaller client with only two locations will still bring in more than $170,000+ in projected annual revenue. Both clients also averaged NPS patient satisfaction scores of 74.24–well above the industry average of 58. 

If you’re a member of an ACO, you have even more opportunities for revenue. Offering a patient CCM every month greatly increases your chances of having the patient attributed to your practice. The more patients correctly attributed to you, the more payments you could receive. 

Many nephrology practices would like to offer their patients CCM services but don’t have enough staff. A fully-managed CCM service ensures you won’t have to hire additional staff, and the cost of the service will be more than offset by the revenue generated. 

Care for Your Chronic Kidney Disease Patients with CCM 

Chronic Care Management ensures nephrology patients have access to a 24/7 nurse line and personalized care every month. These features can help patients manage their exercise and nutrition and, hopefully, delay the progression of their disease.

If you’d like to learn more about how Chronic Care Management can benefit your patients and increase revenue for your nephrology practice, you can start by viewing our Chronic Care Management breakdown.

*Results may vary by provider.

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