6 chronic care management practices to drive success

What is chronic care management?

Chronic care management refers to providers’ efforts to help patients manage chronic conditions such as diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and others. The CCM program offers reimbursement to providers caring for patients with chronic conditions. For patients at risk of hospitalization, it provides greater access to care and lowers related expenses.

How can you be sure you’re following the CCM program's guidelines and providing quality care? Continue reading for six steps for effective chronic care management.

1. Know who can bill CCM services

The first step is to identify providers who can participate in chronic care management billing. In addition to physicians, the following non-physician practitioners can bill CCM services:

• Physician assistants
• Clinical nurse specialists
• Nurse practitioners
• Certified nurse midwives

Federally qualified health centers (FQHCs), rural health clinics (RHCs), and hospitals are also eligible. Note, however, that only one FQHC, RHC, or practitioner — whether a physician or non-physician practitioner — and one hospital can receive CCM reimbursement for an affected patient every month.

2. Understand patient eligibility

As you look to identify which patients would qualify for enrollment in the CCM program, keep these requirements in mind:

• Patients must have two or more chronic conditions.
• The patient’s condition must be expected to last at least 12 months.
• Conditions must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

CMS provides examples of eligible chronic conditions, including:

• Alzheimer’s disease and related dementia
• Cancer
• Cardiovascular disease
• Chronic obstructive pulmonary disease (COPD)
• Diabetes

3. Establish comprehensive care plans for chronic care management

Carriers must preserve full electronic care plans for patients to meet CCM criteria. Practices can provide "person-focused" or personalized care by developing and expanding these care plans.

Here is what a care plan should include:

• Comprehensive assessment (or reassessment) of patient’s physical, mental, and psychosocial needs
• List of patient’s health problems, with emphasis on chronic conditions
• Treatment goals and expected outcomes
• Inventory of resources and individuals involved in care
• Ongoing medication management

Make these care plans accessible to the patient and caregiver, in addition to other providers if needed. Practices can use a patient portal for patients to access an electronic copy of the care plan.

4. Obtain and document advance patient consent

Before providing and billing CCM services, practitioners must obtain the patient's written or verbal consent, which must be documented in the medical records.

When inviting patients to participate in chronic care management, make it clear that they can opt out at any moment and that only one practitioner can supply these services per month. Also, talk about what patients can expect from CCM and any applicable patient cost sharing.

5. Track time spent providing care

Providers will need to track time spent providing non-face-to-face services for each CCM program patient. Calls to patients, prescription management, medication reconciliation, and care coordination with other practitioners and healthcare facilities are just a few examples of related duties. Practices may even employ a chronic care manager to oversee care coordination, coaching, and education.

6. Partner with a care coordination service for chronic care management

If you are interested in the CCM program but your staff does not have time to implement these services, consider partnering with a care coordination service.

Greenway Care Coordination Services (GCCS) supplies a remote care management program integrated into Greenway’s EHR. When you partner with GCCS, you can benefit from increased patient engagement, improved care for patients with chronic conditions, and compensation through the CCM program. GCCS facilitates practices finding eligible patients and increasing enrollment, while ensuring compliance with Medicare.