Should You Launch Care Management In-House or with a Partner?

Should You Launch Care Management In-House or with a Partner?

Chronic Care Management (CCM), introduced by CMS in 2015, has successfully reduced costs and improved patient care for over a decade. A national report based on CMS claims data showed that CCM reduced hospitalization claims by 4.7% and costs by $888 per beneficiary, per year.

But this program has strong compliance requirements and demands dedicated staff, technology, and processes. If you launch an internal CCM program without a comprehensive plan, your program will likely flounder, with low enrollment, costs greater than your revenue, and limited impact on your patients.

A clear plan, and potentially the right vendor, can ensure your program reaches all the patients who need it, improving their care and justifying the cost of the program infrastructure. Let's explore all the critical elements of care management you should consider before you launch an in-house program or partner with a care management vendor.

Introduction to Chronic Care Management

After CMS introduced Chronic Care Management in 2015, practices quickly saw success in reducing hospitalizations and healthcare costs by offering patients 20 minutes of preventive care each month. Because of these successes, many practices have launched CCM to improve their value-based care performance, their patient care, and their fee-for-service revenue. Practices can earn an average of $100,000 in revenue for services provided for 300 patients enrolled in CCM*.

CCM is only for Medicare patients with two or more chronic conditions. Services may be offered under general supervision, which means that the billing practitioner doesn't have to personally perform the services, but the services must take place under their overall direction.

The CCM program must include critical elements, like:

1. Initiating visit (for patients who have not been seen by their provider in the past year)
2. Patient consent
3. An electronic, comprehensive care plan
4. 24/7 access to care
5. Comprehensive care management
6. Support during care transitions (coordinate care between providers, update care plan after hospital or ER visits)

To comply with Chronic Care Management requirements, you must determine which patients are eligible and obtain their consent before enrolling them. You also must have enough staff to:

• Build care plans for each patient
• Operate a 24/7 care line
• Offer 20 minutes of personalized care per patient, per month

Performing all of these functions successfully requires extensive infrastructure, staffing, and technology. For current billing and documentation rules, see the CMS MLN Matters article on CCM.

Questions to Consider

Enrollment: How will you identify and enroll eligible patients?

To qualify for Chronic Care Management, Medicare patients must have two or more chronic conditions expected to last at least 12 months. They must give their consent to enroll in the program and can only enroll under one provider.

On the surface, determining which patients are eligible for CCM might seem straightforward. Most EHRs contain documentation of whether a patient has two or more chronic conditions. However, new patients can become eligible for CCM each month, as they are diagnosed with new health conditions or become eligible for Medicare.

Simultaneously, patients will churn out of the program due to moving to another practice, entering a nursing home, or sadly, passing away. Therefore, you or your CCM partner will need to continuously parse patient data to determine who is eligible for CCM.

If a patient is eligible but no one has reached out to them, your staff will need to:

• Contact them in person, via phone or digitally
• Describe what care management is and the benefits
• Share the compliance requirements
• Document the patient's consent

Often, practices don't have the technology or the available staff to determine patient eligibility on a rolling basis and reach out to patients to enroll them. Many practices also don't have access to the data that would allow them to provide patients with accurate copay estimates. This leads to low enrollment.

Little Colorado Medical Center in Winslow, AZ tried to launch an internal CCM program and was only able to enroll fewer than 10 patients, too few to justify the cost of the program. In just over a year, ChartSpan helped them enroll hundreds of patients.

"We didn't have the expertise. Everything was hard. We knew what codes we could bill for, but we needed some handholding to get CCM going."

Doug Umlah
CCO, Little Colorado Medical Center

When Little Colorado partnered with ChartSpan, we used our parsing technology to identify hundreds of CCM-eligible patients. ChartSpan staff reached out to those patients, with consistent support from Little Colorado, and more than 200 of those patients consented to enroll over the course of one year. This success ensured Little Colorado had high enough enrollment to justify a CCM program and to give more patients access to care management.

Technology: What technology will you need to run CCM?

Chronic Care Management requires extensive technology beyond an EHR. While an EHR is a critical foundation for care management, you also need technology with the ability to:

• Parse data and determine patient eligibility
• Queue inbound and outbound calls
• Track time spent with each enrolled patient, each month

Even if your EHR has features to help you determine patient eligibility, the logistics of clinical care can still prove overwhelming for many practices. For example, you must be able to manage inbound patient calls 24/7, with reasonable wait times.

Queuing Inbound and Outbound Calls

ChartSpan's Service-Level Agreement is to answer inbound patient calls within an average of 30 seconds, even on holidays and weekends. If you aren't able to maintain fast response times for inbound calls 24 hours a day, you will likely need to partner with an outside answering service or a CCM partner with effective SLAs.

You will also need a way to track which enrolled patients have received outbound outreach in a given month, so you can reach out via phone or text to the right patients. Patients who have already received multiple outreach attempts may be annoyed at receiving another, and care managers have to be careful not to miss reaching out to patients who are still awaiting preventive care.

Time Tracking and Care Documentation

Chronic Care Management can't be billed unless care managers devote 20 minutes of care to each patient, per month. This time can be spent on developing the patient's care plan, updating care goals, sending patients educational information, and performing assessments for quality measures like vaccinations, cancer screenings, or cognitive health.

The 20 minutes can also be spent on meeting specific patient needs, such as arranging medication refills, scheduling appointments, sending referrals to their provider, or arranging transportation. Some patients will also require Social Determinants of Health assistance, and care managers can devote time to recommending nutrition, housing, and utility resources.

All of these activities must be documented in the patient's care plan and the time spent on them must be tracked before CCM claims can be submitted.

Staffing: Do you have enough clinical staff to run the program effectively?

Some practices start out with one or two care managers to care for all their patients. That was the case at Breckinridge Health, a ChartSpan client who originally tried to run a program in-house.

"The main challenge was time. I felt as the sole care coordinator for three clinics and eight providers, there was not enough time to devote to looking for potential patients while managing existing patients."

Jennifer Eskridge, RN
Care Coordinator, Breckinridge Health

Performing CCM enrollment and CCM clinical activities at the same time was also overwhelming for Little Colorado Medical Center, who saw frequent turnover for their in-house care coordinator position.

"We had one person dedicated to CCM, and it was too much for one person."

Ashley Wilkie
Outpatient Services Director, Little Colorado Medical Center

Separate enrollment and clinical care teams

As Little Colorado and Breckinridge emphasize, it's difficult for one person, or even a small group of people, to manage both enrollment and clinical care. Identifying and enrolling eligible patients requires ongoing effort that's often abandoned when staff members are focused on covering the 24/7 care line and ensuring enrolled patients receive 20 minutes of care each month.

Because ChartSpan divides enrollment and clinical care over two dedicated teams, Breckinridge was able to increase their enrollment from 72 patients to 722.

"The large amount of staff (ChartSpan) utilizes makes a huge impact on the volume of patients enrolled and managed for CCM services."

Jennifer Eskridge, RN
Care Coordinator, Breckinridge Health

Clinical outbound and inbound teams

Separating enrollment and clinical care is not the only staffing challenge. CCM also requires care managers who can both respond to the care line 24/7 and proactively reach out to patients to work on their care goals and care plans.

During outbound outreaches, care managers will engage in preventive care:

• Updating care goals
• Providing educational information on patients' conditions
• Recommending community groups, classes, or resources
• Screening for patient gaps in care and referring patients back to their provider

This care is meant to help patients proactively manage their health, before their conditions worsen. But care management also demands the ability to respond to new, concerning symptoms and even emergencies on an around-the-clock basis.

The challenges of 24/7 care

Chronic Care Management requires a 24-hour care line. This means a member of your team must be able to respond to calls, texts and emails quickly, even in the middle of the night, on weekends, or on national holidays.

Sometimes patients will call the 24/7 care line because they need medication refills, transportation, or community resources. But they may also call with new symptoms or medical concerns.

At ChartSpan, we have nurses available for triage at all hours. When a call is referred to an RN, they can use Schmitt-Thompson triage protocols and let the patient know whether they should treat their symptoms at home, make an appointment with their provider, visit urgent care, or immediately go to the ER. The triage nurses can also call an ambulance if needed.

In addition to responding to physical health emergencies, the nurse triage line is often responsible for mental health emergencies. CCM requires care managers and nurses who are both available and trained to provide triage 24 hours a day, so a clinician can quickly help those in mental health crisis.

Protecting staff time

Between staffing a 24-hour care line, performing 20 minutes of documented care for each enrolled patient, and identifying eligible patients and enrolling them, a Chronic Care Management program can require extensive work and time from your team.

For practices with 1,000 CCM-eligible patients, partnering with a vendor could save you 674 hours of staff time per year, or 13 hours every week. Collaborating with a vendor can help you protect your employees' bandwidth so they can focus on clinical care and in-person patients. This is especially true if you don't have the ability to hire dedicated staff for care management.

Care management typically requires one full-time care manager for every 300 eligible patients. If that care manager must also perform enrollment, you may need one full-time employee for every 75 eligible patients.

Burnout is already a wide-spread problem for healthcare workers, and building a new, in-house program from scratch can contribute to these feelings of stress and overwork. Partnering with a vendor doesn't eliminate the need for staff to participate in care management: the provider is still in charge of general supervision, and clinical staff will need to respond to notifications about changes in a patients' health.

But collaborating with a vendor allows your staff to focus on areas where they excel, providing in-person care, instead of on enrolling patients, reaching out through repeated calls, or performing documentation or time tracking. Before launching an in-house program, consider whether your staff is able to manage this additional remote workload.

Compliance

Can you meet the compliance and quality requirements of an in-house CCM program? Many practices are familiar with the need to provide 20 minutes of care each month for patients, but less familiar with CCM's other compliance requirements.

During enrollment, your enrollment team must share all the required enrollment information, record patients' consent, and archive that documentation for ten years. Once patients are enrolled, it also becomes critical to create a comprehensive, electronic care plan with care goals that patients can access, to staff a 24/7 care line, and to provide 20 minutes of meaningful, documented care each month.

If you have not accurately documented the care provided, you will not be able to submit claims and receive reimbursement for the care management services you provide. A partner can send you claims and documentation for your review, so you can quickly submit the claims and receive the reimbursements you earned. See the CMS MLN Matters article on CCM for current documentation and billing requirements.

Quality

Beyond basic compliance, you will need staff who are confident in their ability to provide high-quality, remote care. Some vendors, like ChartSpan, offer built-in quality programs to help you go beyond compliance and improve your performance on quality measures and care coordination assessments.

While CCM does not have specific quality requirements, not using your care management program for quality can lead to lower overall quality scores, making your program less effective for patients and less effective at generating shared savings. Care managers can address quality measures from vaccinations to blood pressure and A1C readings with patients on a regular basis, so your practice can close care gaps and improve quality performance.

Once you have taken into account all these requirements of care management, you're prepared to determine whether you should launch a CCM program in-house or by partnering with a vendor.

In-House vs Partner: Side-by-Side Comparison

The table below summarizes the conditions under which each approach typically works best.

If most rows in the right column describe your situation, a partner is the lower-risk path. If most rows in the middle column describe you, you have the foundation to consider building in-house.

The Real Cost of Building In-House

Practices considering an internal CCM program should plan for the following year-one investment categories:

• Enrollment FTE: One specialist can typically onboard 75 new patients per month. You will likely need 2 to 3 to manage patients responding to your calls.
• Clinical FTE: One care manager can manage 300 enrolled patients if they are not also performing enrollment.
• 24/7 care line coverage: Significant additional cost if outsourced to an answering service, or at least 4 to 5 full-time employees if staffed internally to ensure coverage across nights, weekends, and holidays.
• Compliance and billing setup: Internal legal and compliance review, biller training on CCM-specific codes, claims process build, and ongoing audit support.

Frequently Asked Questions

Making Your Decision on How to Launch Care Management

Your practice knows how to provide exceptional in-person care. But when launching Chronic Care Management in house, you will need extensive staff, custom technology, well-established enrollment practices, and expertise in care management compliance and quality. Without these features, you might enroll too few patients to generate consistent revenue or not fulfill all the requirements to receive reimbursement.

Whether you build internally or partner, the operational requirements above are the same. Only who handles them changes. ChartSpan partners with 175+ practices across the U.S., including FQHCs, RHCs, multi-specialty groups, and specialties. Our programs generate average cost savings of $2,457 per patient per year and $100,000 in average new practice revenue per 300 enrolled patients. If you'd like to see what a customized program would look like for your patient population, talk to a CCM expert.

*Results may vary by provider.