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How Do I Start a Chronic Care Management Program?

If you’re just being introduced to chronic care management (CCM) you may be wondering if it’s time to consider setting up a chronic care management program. With several different chronic care management training resources available, it’s easy to learn the ins and outs of what CCM entails. And that’s important if you want to start a CCM program. In this blog, we explore CCM programs, how to get started, and other important information you need to do it the right way.

What Are the Steps to Starting a Chronic Care Management Program?

To get started with a CCM program, you’ll need to take several steps to make sure you not only reach the right patients. It’s important to comply with any Centers for Medicare and Medicaid Services (CMS) CCM requirements to get the most out of your program. This is especially true for those seeking reimbursement.

1. Understand Chronic Care Management and Develop a Plan

Chronic care management is the approach used by physicians to help patients that meet the requirements of two or more chronic conditions that will last 12 or more months or until death. The guidelines list several different conditions, such as diabetes, COPD, and hypertension. Once you explore the definitions and requirements set forth by CMS, you’ll be able to develop a plan. This strategy should go through the logistics of operating a CCM program as well as the resources required. It’s important to note that following the CMS guidelines and best practices will help you get the most out of your pro

2. Identify the Patients You Will Serve

To find patients who would benefit from chronic care management, physicians should use their current database of electronic medical information. Ideally, your Electronic Health Record (EHR) should enable you to process patient eligibility and generate a report that you can use. Remember, patients will meet the criteria outlined by CMS if they are significantly at risk of death, acute exacerbation and/or decompensation, or functional decline due to two or more diseases. The next stage is to choose the candidates who are the best fit for treatment.

3. Educate and Enroll Patients

You must not only identify those qualifying patients but also secure their consent to participate in the program. You should be Informing them about the advantages of chronic care management in order for them to make an informed decision. Potential patients need to be aware of how the program operates and how it can affect their health. You should also emphasize that they are always free to refuse, transfer, or end their participation in the program. Give them a formal consent form to sign, indicating their want to take part in the program if they are interested.

4. Provide CCM and Encourage Patient Engagement

Once the patient has been formally enrolled in the CCM program, it is time to begin providing them with standardized CCM services. The initial step is to assess the patient’s medical, functional, and psychosocial needs. After the initial assessment, you should develop a patient-centered treatment plan. Make management plans for patients that include recommendations for preventative actions, and monitor the patient’s adherence to those plans. After you’ve completed the care plan, make it accessible to the patient and other clinicians. Keeping patients engaged with their health, consistent communication is essential. Whether you have patients use a portal or communicate with a CCM management service, keeping them engaged will help them feel comfortable with continuing treatment.

5. Complete Billing and Reimbursement

Each month, it’s required to confirm that the patient’s requirements were met before submitting CCM billing under CPT code 99490. As defined in the patient’s treatment plan, twenty minutes of professional care must be spent on non-face-to-face chronic condition healthcare. Even if the patient’s visit lasts longer than 20 minutes, you can only submit one unit of 99490 every month for each individual patient. To get reimbursed, you must keep track of all CCM-related actions and the time you spent working with the patient. This ensures that no competing billing codes are used.

How Can You Create a Plan? 

Sharing patient data, improving care transitions, and keeping tabs on prescriptions are all possible thanks to chronic care management services, which can also boost your facility’s bottom line, improve Medicare compliance, and help you provide better care overall. You have all of these capabilities with TimeDoc Health. You can start planning your own CCM care plan for patients in an easy-to-use platform. That’s because TimeDoc assists healthcare providers in scaling up the implementation of evidence-based care management initiatives by integrating directly to your EHR. 

Who Can Write a Care Plan for Chronic Care Management?

Only licensed clinical staff members can write a CCM care plan, in partnership with a physician and patient. Care plans are necessary to help organize and coordinate patient-centered development and self-management. To achieve clinical outcome goals, CCM care plans should be adjusted to specific patient needs and include certain essential components, such as goals, metrics, interventions, and assessments. 

According to the CMS, a comprehensive care plan should include elements like: 

  • Problem list
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Cognitive and functional assessment
  • Symptom management
  • Planned interventions
  • Medication management
  • Environmental evaluation
  • Caregiver assessment
  • Interaction and coordination with outside resources, practitioners, and providers
  • Requirements for periodic review
  • When applicable, revision of the care plan

For a clearer picture of chronic care management care plans and how to write them, here’s a chronic care management template for you to compare to your own forms.

What Conditions Qualify for Chronic Care Management?

Because a patient needs to have two (or more) chronic conditions that will last 12 months or longer, qualifying for CCM can be fairly intricate. This is especially true, because other requirements for CCM qualification include the risk of death, acute exacerbation and or decompensation, or functional decline. However, CCM does cover many chronic conditions that your patients could have and gives them the ability to take control of their healthcare. But what conditions qualify? According to the CMS, some—but not all—of the conditions that qualify for CCM include: 

  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Cancer
  • Cardiovascular disease
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Diabetes
  • Hypertension

These CMS chronic care management guidelines require 20 minutes of clinical staff time every calendar month guided by a physician or other certified healthcare provider. Because of this requirement, a patient’s care coordinator can help facilitate additional scheduled treatments to tackle problems that might otherwise go unrecognized by the patient. 

CCM services also include structured patient health information recording, the maintenance of a comprehensive electronic care plan, and the monitoring of transitions of care and other care management services. Finally, the development of a comprehensive care plan—which must be established, monitored, implemented, and made available to the patient—is essential to successful treatment.

Engage Your CCM Patients

Once you start your CCM program, TimeDoc offers simple chronic care management solutions that are directly integrated into medical facilities’ electronic health records (EHR). Patients with chronic conditions need the ongoing medical care offered by CCM because they frequently have limitations in their daily activities and run the risk of functional decline. We provide flexible services that can supplement your care coordination efforts by taking on some or all of the patient care if you don’t have the team members to handle CCM. If you’re interested in a CCM solution, request a demo on our website!