A typical CCM model creates a framework for healthcare teams to develop individual care plans. These plans encompass many health objectives including: keeping track of a patient’s health problems and goals, monitoring the patient’s progress, and recording all aspects of the patient’s treatment plan.
Put simply, a CCM plan outlines the specific care a patient needs and how providers will coordinate it. Here are some examples of different duties executed throughout CCM.
- Care coordination is where a patient’s healthcare team begins to create a comprehensive care plan. This plan considers the patient’s medical history, current health status, individual needs, and unique preferences.
- Remote follow-up meetings are regularly scheduled telemedicine check-ins where a care team connects with patients to assess their health status. Pending the outcome of each discussion, the care team will choose to make certain adjustments to the patient’s care plan. The purpose of these meetings is to ensure that every patient receives optimal care and support between appointments.
- Patient education is meant to help chronically ill people navigate the complex world of healthcare. Throughout ongoing follow-up calls, the care team works with patients to provide additional education to help patients better understand their condition and formulate strategies to manage their symptoms.
- Medication management is where care teams monitor all aspects of chronically ill patients’s complex medication regimen. As a part of the CCM process, the care team will ensure that patients take the correct dosage at the appropriate times, help the patient monitor for potential side effects or drug interactions, and make ongoing adjustments based on how the patient reacts.
Remote monitoring allows the care team to monitor a patient without adding additional in-person visits. To make this process function smoothly, patients wear monitoring devices so the care team can monitor the patient’s condition in real-time. Remote patient monitoring is critical for identifying potential issues before acute health episodes occur.
CMS Chronic Care Management Guidelines
The CMS started offering a groundbreaking program around 2014 to care for Medicare and Medicaid patients battling chronic diseases. Basic eligibility criteria for this program mandate that:
- Patients have at least two chronic conditions that are expected to last for a minimum of 12 months or until the end of life.
- Patients have a written care plan that is regularly reviewed and updated by their healthcare provider.
The CMS’s Chronic Care Management program aims to transform the healthcare landscape by providing comprehensive care and support for patients with chronic conditions. By offering financial incentives to healthcare providers who offer CCM services, the program encourages participation in this pivotal initiative.
While some facilities may have experienced initial challenges in navigating the program, many have since found it to be a valuable tool for improving care management and patient outcomes. Consider this case study on Dunbar Medical Associates, PLLC, a large primary care practice in West Virginia. Despite initial challenges, the practice recognized the program's potential to improve patient care and financial health, and they committed to making it work.
To start, Dunbar hired a full-time chronic care management nurse to provide proactive outreach to patients. However, frustration set in when they realized their EHR did not efficiently document required information such as patient enrollment and care planning. The CCM nurse had to manually toggle between the EHR and Excel, making tracking highly inefficient and tedious.
The solution? TimeDoc Health. TimeDoc's EHR-integrated CCM platform and services impressed the Dunbar team as they simplified documentation, increased patient engagement, and automated billing reports. In just under three months of using TimeDoc Health, Dunbar enjoyed such benefits as:
- A remarkable increase in the number of patients receiving CCM services each month—a mere 50 to an impressive average of 450 patients.
- The ability to closely monitor the progress of each CCM patient in real-time and focus attention on non-completed patients.
- A revenue boost from $20k to $150k in annual reimbursement, with projected earnings of $225K the following year.
Along with these benefits, all Dunbar providers and clinical staff were able to easily navigate the “user-friendly” TimeDoc platform and calculate their time spent with CCM patients. Dunbar's Practice Manager, Nancee Barnette, summed it up nicely: “I feel strongly during the most challenging days upon us and ahead of us, chronic care management will be a means to care for our most vulnerable patients, as well as offer a source of revenue.”
How CCM Platforms Enhance the Chronic Care Management Process
Managing patient data, keeping up with billing, scheduling various appointments, and creating effective care plans is a lot of work. And juggling all of these processes places a significant strain on care teams. Thankfully, all of this can be managed using a CCM platform.
Take TimeDoc Health, for example. The TimeDoc platform automates various aspects of the care planning process, and streamlines the documentation and billing process to give care teams more time to focus on what matters. Additionally, one of the most critical failures in the CCM process is limited and inconsistent communication between stakeholders. A CCM platform like TimeDoc, when integrated in your EHR, standardizes and improves access to data for physicians and other clinicians involved in the treatment process.
At a glance, TimeDoc’s CCM platform facilitates information sharing within care teams, supports ongoing patient care, and makes it possible to monitor adherence to treatment regimens. With this high-level support, care teams limit hospitalizations, improve the patient experience, and achieve optimal health outcomes.
But what about the personal side of things? Alongside our platform, TimeDoc provides staff augmentation services, to ensure patients receive the constant contact they need without putting additional strain on physicians and their teams. TimeDoc gives our partners access to a dedicated team of clinical care coordinators who personalize care for each of your patients. Learn more about our solution here.
Revitalize Your Chronic Care Management Program With TimeDoc Health
As the prevalence of chronic illnesses continues to climb, the need for improved CCM is even more urgent. According to one report, chronic diseases will affect approximately 164 million Americans—nearly half (49%) of the population—by 2025. In short, time is of the essence, and healthcare teams need all the help they can get.
Whether you're just starting to build a CCM program or want to improve what you already have, TimeDoc Health is here to support you and your patients. Our platform and care management services make it simple to engage with patients, stay in the loop regarding patient health statuses, deliver valuable health education, and much more. See what TimeDoc can do for you and request a demo today.
