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What Conditions Qualify for Chronic Care Management?

According to the Centers for Medicare and Medicaid Services (CMS), some of the most common conditions that qualify for chronic care management (CCM) services include:

  • Diabetes
  • Cancer
  • Hypertension (high blood pressure)
  • Cardiovascular disease
  • Chronic obstructive pulmonary disease (COPD)
  • Asthma
  • Arthritis, including osteoarthritis and rheumatoid arthritis
  • Alzheimer’s disease and other forms of dementia
  • Chronic kidney disease
  • Depression and other mental health conditions

The heart of CCM is giving patients with chronic conditions the personalized care they need. This requires a level of support far beyond traditional healthcare services. If you’re wanting to engage your patients in chronic care management solutions, but aren’t sure where to begin, keep reading. In this article, we’ll go over the fundamentals of CCM and how TimeDoc Health can simplify the process and enhance patients’ quality of life.

What Is the CMS Definition of Chronic Care Management?

The CMS defines Chronic Care Management (CCM) as non-face-to-face services to a beneficiary. This beneficiary must have two or more chronic conditions that:

  • Are expected to last 12 months, at minimum, or until the end of the patient’s life.
  • Place them at significant risk of death, acute exacerbation/decompensation, or functional decline.
  • Require an extensive, consistent level of treatment, monitoring, or other regular interventions.

What Does Chronic Care Management Include?

CCM includes a comprehensive, coordinated approach to care, with a focus on preventing complications, improving patient outcomes, and enhancing patients’ quality of life. These services typically include the following:

Personalized Chronic Care Management Care Plan

The foundation of CCM is personalized care plans that cater to each patient’s unique needs. This approach is critical to giving patients the best possible support, taking into account their medical history, current health status, and even social determinants of health. 

If you don’t have enough staff or resources to maintain such a program, you’ll be happy to know that you can outsource these services and still receive chronic care management reimbursement. According to the CMS, a billing practitioner can enlist external support to provide the clinical staff aspect of CCM services, given that they adhere to all the regulations required for billing CCM to the Physician Fee Schedule. In fact, TimeDoc Health offers staff augmentation services for this purpose, with a team of clinical staff who personalize CCM for patients. You’ll get a dedicated team of clinical staff to help you personalize care for each and every patient. All of our care coordinators are experienced in delivering care that improves health outcomes. 

Regular Communication

CCM patients receive ongoing communication and guidance from a dedicated care team. The care team ensures regular contact with patients, which can include reminders for appointments, follow-up after hospital discharge, and support for patients between appointments. 

With TimeDoc Health, personalized care planning is made even more efficient. The TimeDoc platform integrates directly into the electronic health record (EHR), making it easier to access and track patient information. TimeDoc Health’s platform and care coordinators help streamline your care planning process and allow you to stay on top of communication.

Medication Management

Patients with chronic conditions often have multiple medications to manage, making it challenging to keep track of dosages, refill schedules, and potential interactions. Medication management is a vital aspect of CCM that helps patients adhere to their medication regimen and avoid potential complications. 

What is an example of chronic care medication management? Let’s say you’re using TimeDoc Health to provide CCM services for a patient with type 2 diabetes. The patient takes several medications, including metformin, insulin, and medication for high blood pressure. If the patient misses a dose or is running low on a prescription, the TimeDoc care team sends a reminder to take their medication or coordinates with the patient’s pharmacy to refill the prescription.

Coordination of Care

CCM care teams also help patients navigate the healthcare system. This assistance involves:

  • Ensuring the effective sharing of information
  • Scheduling appointments efficiently
  • Smoothing out transitions between healthcare providers

To illustrate, suppose a patient with heart disease is seeing a cardiologist, a primary care physician, and a nutritionist. Coordination of care would involve ensuring that all three providers are aware of the patient’s care plan, medications, and any other relevant information.

Health Education and Coaching

Health education and coaching play an important part in CCM by empowering patients to take an active role in their health. For example, patients with hypertension may receive education on monitoring their blood pressure, following a healthy diet, and engaging in physical activity. The care team may also provide emotional support and address barriers to adherence. 

Remote Patient Monitoring

Remote patient monitoring (RPM) in CCM involves the use of technology to track a patient’s health status from a remote location. A patient with diabetes, for instance, may use a cellular-connected blood glucose monitor to track their blood sugar levels. The device then transmits that data to their care team. Members of the care team can monitor the patient’s data and adjust their care plan as needed.

TimeDoc: The Secret to Successful Chronic Care Management Workflow

If you’re looking for a comprehensive and effective solution for CCM, look no further than TimeDoc Health. When you have the TimeDoc platform and services on your side, you get:

  • A dedicated care coordination team to engage with patients on a regular basis.
  • Unparalleled reporting functionality to analyze key metrics and gain a deep understanding of your program’s ROI.
  • Automation that accurately organizes charges and posts directly to your EHR, saving valuable time and effort.
  • Physician-created care plans and customizable templates that make the care planning process faster and more efficient than ever before. 
  • Central storage for all monthly encounter summaries, patient consents, and care plans for easy access.
  • Improved care staff efficiency with dashboard features that provide real-time visibility into key performance metrics. 

If the same old healthcare practices are leaving you feeling drained and unfulfilled, then try CCM with TimeDoc Health. Our innovative approach will help you achieve greater efficiency, effectiveness, and patient satisfaction. See how it all works and request a demo today!