Three Ways Every Provider Can Improve Health Care for Their Patients

The push for value-based care has driven practices to try new preventative programs and processes that claim to provide better care for their patients. With the population of patients who need additional care rapidly growing, it can be a difficult change. For some, it can be overwhelming to decide which programs and changes, if any, are worth the time and investment and will actually produce positive outcomes for their patient population.

In 2015, the Centers for Medicare & Medicaid Services (CMS), introduced reimbursement for offering Chronic Care Management (CCM) services, a preventive care program for Medicare patients with multiple chronic conditions. In this article, we will explore the patient benefits of a CCM program and assess its worthiness as an effective value-based care program.

Benefits of Chronic Care Management

In 2015, the Centers for Medicare & Medicaid Services (CMS), introduced reimbursement for offering Chronic Care Management (CCM) services. This preventive care program helps Medicare patients with multiple chronic conditions. As many practices have seen, CCM in health care is a great way for both patients and providers to save money, helping patients access the help they need and better meet their health goals.

Let’s start with three of the top advantages of a CCM health care program.

1. Access to Care

Most patients have a reactive approach to health care, visiting their provider only when they get sick or injured. In a CCM program, the emphasis is on proactive, preventative care. The CCM care team proactively performs monthly telephonic and electronic check-ins with enrolled Medicare beneficiaries.

Medicare requires 20 minutes of clinical staff time to be performed and documented in order for CCM to be billable under CPT code 99490 (G0511 for RHC/FQHC) each calendar month. This proactive approach allows clinicians to provide preventative services specific to the CCM patients’ chronic conditions before their health worsens.

In addition to preventative services, Medicare requires that CCM services include 24/7 access to care, such as a nurse hotline. This two-pronged approach of reaching out proactively for preventative care but also providing extended availability makes Chronic Care Management a powerful program. CCM’s heightened access to care is intended to reduce or slow functional decline, and is proven to reduce hospitalizations and emergency room visits.

2. Health Care Savings

Even with a small monthly coinsurance requirement, patients who are eligible and enrolled in a CCM program are shown to reduce their annual health care expenditures.² CCM services can help patients reduce their overall healthcare spending in multiple ways:

Preventative care keeps patients healthy and out of the hospital.
A 24/7/365 nurse line reduces the likelihood that a patient would go to the emergency room for a non-urgent issue.
The 24/7 care management access allows patients to ask questions directly to qualified health care professionals, without having to go in for an office visit.
The care team can help assist with finding less-expensive prescription options.

Medicare claims data shows us that with CCM, unnecessary hospital visits can be reduced by at least 4.7%¹and ED visits by 2.3%.³ Additionally, Chronic Care Management saves Medicare approximately $74 per patient, per month.²

3. Achieving Health Care Goals

Care management clinicians work to equip patients with the tools they need for self-management of their chronic conditions. The clinicians address each patient’s chronic conditions individually and together with their primary care or specialty provider, build goals to improve their health outcomes. These goals are then documented in a comprehensive care plan and referenced during each interaction with the patient.

Chronic Care Management requires the construction of a comprehensive care plan that is accessible at any time. This plan is an all-encompassing document where the care coordination team documents every interaction with the patient. It also includes the patient’s medical history, list of healthcare providers, health conditions, and a medication list. The comprehensive care plan is stored like a medical record in the provider’s electronic health record (EHR) and is available to the patient, provider, and approved caregivers.

Challenges CCM Patients May Face

Of course, CCM isn’t without its challenges. Some of the challenges that patients in an in-house CCM program might face include:

Busy providers: The health care system is often overworked. Providers may be stretched thin and struggle to meet the CCM patient’s expectations, especially if their support staff is lacking.
Inadequate patient education: Many patients don’t fully understand their conditions and don’t know what they need to do to see progress. For example, a patient who doesn’t know what their medication does might be more comfortable skipping doses or taking it in a way that impacts absorption. A lack of comprehensive patient education can affect compliance and satisfaction.
Poor coordination: Since CCM patients often see several providers, it can be challenging to coordinate care and share information between these clinicians. One doctor may not be aware of a new diagnosis or medication, which can cause an incomplete picture and impact the quality of care.
Poor monitoring: Follow-up appointments ensure that the provider is up to date on patient progress and concerns. If the follow-up is inconsistent or nonexistent, patients could lose accountability, and outcomes may suffer.

Addressing these challenges calls for a complete buy-in of preventative care, including an organized, well-staffed and knowledgeable CCM team. Some practices struggle to offer this level of in-house care due to the training, technology, and the hiring it calls for. Thankfully, a practice of any size can still attain an exceptional CCM team through fully-managed CCM services instead of an in-house program.

How a Fully-Managed CCM Program Benefits Your Patients

A fully-managed CCM program allows you to work with a dedicated team devoted to filling in the gaps. They’ll take care of the everyday tasks of CCM like reaching out to patients, updating care plans and coordinating care with providers. Managed CCM can help improve and expand the program without increasing the demand on your practice, leaving your team to focus on the patients in front of them.

A robust CCM program should be an extension of your team, working in tandem with the practice to deliver care that aligns with your goals. You’ll always be in the loop and can easily incorporate CCM data into clinical and administrative workflows.

Here at ChartSpan, for example, we offer a wide range of valuable programs to help you reach your business goals and improve patient care, including:

24/7 clinician communication: If your patients have questions, they can reach out to a clinician on our team for fast, knowledgeable advice.
Enrollment services: Identifying eligible patients is often an overlooked part of CCM. We take care of this step, as well as with outreach and enrollment.
Regular reports: We deliver regular reports and documentation to keep you updated on patient interactions, time spent on care, and patient status.
Logistics assistance: Our team can help patients schedule appointments, refill medications and access test results. We can also assist with finding transportation, mobility solutions and home care.
Medicare compliance: Under Medicare, CCM needs to meet certain conditions. We keep track of everything to make sure you meet these requirements.

A managed service provider can help you make the most of your CCM program so you can improve care and maximize revenue while staying focused on your in-person patients.

ChartSpan Gives Your Team the Tools to be Successful

The benefits of CCM are vast, especially for patients. Preventative care with extended resources leads to overall better health and with the help of preventative care and extended resources, patients can enjoy overall better health and access to care. Access to care leads to fewer hospitalizations and emergency room visits, ultimately reducing overall health care spending. Better care helps improve patient outcomes and helps patients achieve health care goals that are specific to their needs. If providers intend to move towards effective, evidence-driven value-based care, a program like this is not only crucial to patients with chronic conditions, but to our health care system as a whole.

The ChartSpan team is dedicated to making CCM simple and effective for you and your patients. As an extension of your team, we work with you to make your lives easier. ChartSpan is a robust program that serves a wide range of practices, including primary care, specialists, Federal Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs). We support you every step of the way, from enrollment to billing, and work with any EMR.

Request a demo today to see how ChartSpan can simplify CCM for your practice.

¹ https://innovation.cms.gov/files/reports/chronic-care-mngmt-finalevalrpt.pdf

²https://innovation.cms.gov/files/reports/chronic-care-mngmt-finalevalrpt.pdf

³ https://acl.gov/sites/default/files/programs/2017-12/TIM%20TALKS_Business%20Planning_Care%20Management_May%2031_2017.pdf