Roughly six in ten adults in the United States have at least one chronic condition, according to the Centers for Disease Control and Prevention. Perhaps even more compelling, the CDC also reports that about four in ten adults have two or more chronic conditions. These patients deserve every opportunity to live full, rich lives with the support of a high-quality medical team.
Yet, chronic care management is often considered complex, time consuming, and burdensome. That’s not for lack of care and effort on the provider’s part—quite the opposite actually! It’s more that with increased patient loads and the very real potential for burn out, there’s simply too much to do and not enough time in the day.
Fortunately, there is a solution. A chronic care management program combined with a powerful, intuitive software solution can actually save time and money while also improving patient outcomes.
What Is a Chronic Care Management Program?
A CCM program is a way for providers and healthcare organizations to manage the treatment and relationship of patients with chronic conditions. These programs typically have documented workflows that lead a patient from program enrollment through appointment scheduling, necessary screenings, required consent, education, care and medication management, and so much more.
What are the Chronic Care Management Requirements to Start a Program? →
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 program.
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.
Related: How to Manage Chronic Disease and Make Your Program a Success →
How to Create a CCM Care 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.
Learn More: What Does a CCM Care Plan Look Like? →
TimeDoc Health: Chronic Care Management, Simplified
Healthcare organizations and medical providers deserve cutting-edge software programs and other solutions that can help them more effectively implement and manage their CCM programs. At TimeDoc Health, we’re on a mission to do just that—to help you create patient success stories by improving their quality of life with the power of CCM programs.
With TimeDoc Health, you can access:
- Experienced, flexible, and trained care coordinators to support your efforts
- Time savings with CCM billing and automated reports
- Comprehensive training sessions on how to best use and implement the TimeDoc platform
- Physician-created templates that support services for each of your patients
- Assistance with billing for behavioral health integration (BHI), transitional care management (TCM), and complex CCM codes
Ready to find out how TimeDoc Health can revolutionize your chronic care management program? Request a demo today.
