Chronic Care Management (CCM) programs, introduced by the Centers for Medicare and Medicaid Services (CMS) in 2015, represent a significant opportunity for healthcare practices to enhance patient care and improve revenue streams. These programs reward providers for delivering value-based care to patients with multiple chronic conditions beyond the traditional office visit. By offering a holistic, patient-centered approach to managing chronic illnesses, CCM programs can lead to better patient outcomes, reduced hospital readmissions, and improved cost-effectiveness in healthcare.
For many healthcare practices, however, the prospect of launching a CCM program can feel overwhelming. Already facing demanding schedules, limited resources, and stretched staff, practices may find the idea of creating, implementing, and managing an in-house CCM initiative daunting. From educating and enrolling eligible patients to ensuring consistent monthly contact and navigating CMS compliance, the challenges can seem significant. Concerns about startup costs and the additional workload often contribute to why CCM programs, despite their proven benefits and the high percentage of eligible Medicare beneficiaries, remain underutilized.
This comprehensive guide aims to demystify the process of starting a chronic care management program. We will break down the essential steps involved in creating a successful CCM program, from understanding program requirements and patient eligibility to developing patient engagement strategies and ensuring accurate billing. We will also explore how partnering with a CCM service provider, like ChartSpan, can alleviate the administrative burden and optimize the benefits of CCM for your practice and your patients.
10 Essential Steps to Launch Your Chronic Care Management Program
Implementing a Chronic Care Management program offers a powerful way to boost practice revenue while simultaneously elevating the quality of care for patients managing chronic illnesses. However, success hinges on careful planning and meticulous execution. Here are ten critical steps to guide your practice in establishing a thriving CCM program:
1. Thoroughly Understand CCM Program Requirements
The potential benefits of a well-executed CCM program are substantial, but the program’s complexity is undeniable. Before committing to an in-house CCM program, a comprehensive understanding of its requirements is crucial. It’s important to stay informed about ongoing updates and expansions from CMS to adapt your strategies accordingly. A proactive approach to understanding the program’s demands will minimize the risk of encountering unforeseen challenges related to documentation, time tracking, care plan adjustments, inter-provider communication, and patient/caregiver interactions.
Managing a CCM program internally necessitates operating a 24/7/365 care line. Your staff will also assume the role of CCM care managers, conducting frequent monthly patient outreach, updating care plans and goals, assisting with prescription refills, and coordinating transportation when needed. Maintaining strict compliance and accurate billing records is also paramount. The increased workload may necessitate hiring and training additional staff.
To secure CMS reimbursements, meticulous documentation of patient health information and provided care management services is mandatory. Practices must fully grasp CMS billing guidelines, verify patient eligibility, and ensure sufficient staffing to manage care coordination and maintain consistent monthly communication. These are just some of the critical considerations for practices embarking on a comprehensive CCM program.
2. Assess Resources, Infrastructure, and Workflow Adaptations
Prior to launching a CCM program, a detailed assessment of your practice’s resources, staffing capacity, existing workflows, and infrastructural needs is essential. This evaluation will highlight areas that require adjustments or upgrades to support effective CCM operations.
Consider the infrastructural demands of CCM. Depending on the program’s scope, investments in technology may be necessary. This could include upgrading your telecommunication system to handle increased outbound patient check-in calls and inbound care line inquiries. Developing a strategy to automate and standardize workflows is also vital for ensuring consistent compliance and efficiency across all CCM activities.
Partnering with a specialized CCM company like ChartSpan can significantly reduce the need for additional staffing. However, your existing team will still play a role in reviewing patient eligibility lists, care plans, and clinical notifications from your CCM partner’s nurses, who operate under the supervision of your physicians.
Identifying an internal champion to lead the CCM implementation is also critical. While a CCM partner can provide implementation support, an internal leader is needed to coordinate meetings, manage communication, set timelines, and oversee the program’s scope within your practice.
CCM programs are most effective when implemented at scale, which can be challenging for practices limited by staff, time, and resources. A CCM partner like ChartSpan offers the advantage of scalability, with established staff and infrastructure ready to meet CMS requirements, maximize patient enrollment, and enhance the patient experience.
3. Verify Patient Eligibility for CCM Services
Before program implementation, it’s crucial to determine if your patient population includes a sufficient number of eligible individuals to justify launching a CCM initiative. CCM is available to Medicare Part B beneficiaries with two or more qualifying chronic conditions expected to last at least 12 months or until the end of life.
Practices managing CCM internally must analyze their Electronic Health Records (EHR) to generate a list of potentially eligible patients. Common qualifying conditions include COPD, diabetes, hypertension, and behavioral health conditions.
Approximately 82% of Medicare beneficiaries meet the eligibility criteria for CCM services, making it a valuable program for practices serving a significant population of patients aged 65 and older. Specialty practices like cardiology, nephrology, and urology, which often cater to older patient demographics, can particularly benefit from CCM.
Patient eligibility for CCM is not static. Patients become eligible upon enrolling in Medicare or receiving a diagnosis of a second chronic condition. Conversely, patients may become ineligible if they enter long-term care facilities or pass away.
Practices running their own CCM programs are responsible for continuous monitoring and updating of patient eligibility lists. CCM partners can streamline this process by providing regularly updated lists for provider review and approval, adhering to CMS guidelines.
4. Implement Patient Education and Enrollment Strategies
Patient enrollment is paramount to the success and financial viability of your CCM program. Patients are more likely to enroll when they clearly understand the benefits of Chronic Care Management and its potential to improve their health journey. Therefore, all providers, clinical staff, and CCM partners should be prepared to effectively educate patients about CCM.
The enrollment process involves three key phases: pre-enrollment education, the enrollment process itself, and post-enrollment welcome and onboarding.
Pre-Enrollment Education:
Prior to initiating enrollment, launch a comprehensive patient education campaign using various channels such as in-person discussions, phone calls, direct mail, and informational materials in your office. Your practice plays a vital role in introducing CCM, building patient trust, and generating program enthusiasm.
Utilize brochures, posters, and waiting room slideshows to educate patients during office visits. Text messages, voicemails, and mailed materials can also be used to introduce the program to eligible patients before seeking their consent to enroll.
A strong CCM partner should assist in developing effective educational messaging, utilizing proven informational language. They can also train your staff on CCM benefits, ensuring confident patient communication. Furthermore, partners can provide pre-designed emails, voicemail scripts, call scripts, mailers, and printed marketing materials for your use.
The Enrollment Process:
Following the education phase, the next step is to obtain patient consent and enroll them in CCM. Enrollment calls typically include:
- Patient identity verification.
- Explaining the numerous benefits of CCM.
- Highlighting unique program features like monthly check-ins, personalized care plans, care coordination, and 24/7 care line access.
- Clarifying that Medicare covers CCM, but standard deductibles and copays apply.
- Informing patients about their right to unenroll at any time and that enrollment is limited to one provider at a time.
- Explicitly asking for patient consent to enroll.
- Recording and securely archiving enrollment calls for a minimum of 10 years.
Patient enrollment requires explicit verbal consent. While some clinical staff may handle enrollment calls, many practices prefer leveraging trained enrollment specialists from a CCM company. These specialists possess in-depth CCM knowledge and are adept at addressing patient questions and concerns. They also dedicate focused time to enrollment, freeing up clinical staff for other responsibilities. ChartSpan’s enrollment specialists achieve an average enrollment rate of 45%.
An effective CCM partner will also utilize patient insurance and demographic data to accurately estimate patient copays and transparently communicate financial obligations.
Post-Enrollment Onboarding:
Even after enrollment, patients may still have questions or require further clarification about the program. A robust CCM program provides resources to address these needs. ChartSpan provides patients with a welcome packet containing detailed information about CCM services, frequently asked questions, and contact details for care managers and the 24/7 care line. Enrolled patients also receive a personalized welcome call from their dedicated care manager.
Ensuring patients feel welcomed and well-informed immediately after enrollment fosters trust in the program and establishes a solid foundation for a successful patient-provider partnership.
5. Develop Continuous Patient Engagement Strategies
For practices without a CCM partner, developing robust patient engagement strategies is crucial. Maintaining patient activation, education, and support post-enrollment is essential for achieving positive clinical outcomes and sustaining high enrollment levels.
Care managers play a key role in this ongoing engagement. They can share tailored dietary and exercise plans, monitor progress and adherence to wellness plans, and connect patients with resources addressing Social Determinants of Health (SDOHs), such as transportation assistance, financial aid programs, and community activity recommendations.
Your CCM program should also incorporate re-engagement strategies for patients who become unresponsive to monthly care manager calls. This may include utilizing voicemails, text messages, and emails to re-establish contact. CCM partners like ChartSpan bring extensive experience in patient engagement and re-engagement techniques to optimize program participation.
6. Outline the Patient Care Journey and Care Plans
Patient support throughout their wellness journey is at the heart of a successful CCM program. Care managers should utilize personalized wellness plans, individualized care goals, and preventive care strategies to promote positive clinical outcomes and improve the quality of life for enrolled patients.
CCM care managers should be trained to identify care gaps and proactively assist patients in scheduling necessary appointments, screenings, and vaccinations to close these gaps. They should also be equipped to recognize signs of social isolation and behavioral health challenges, and administer depression screenings like PHQ-2 assessments. Furthermore, they must be prepared to assist patients with medication refills, transportation access, and food resources if SDOH barriers are identified.
ChartSpan employs SMART (Specific, Measurable, Achievable, Relevant, and Time-Bound) goal setting principles to help patients define personalized care goals. Our ChartMarkers program systematically assesses patients’ conditions, pinpoints areas needing additional attention, and facilitates timely interventions. Our assessments include:
- Clinical assessments.
- Medication adherence assessments.
- Quality assessments to identify care gaps.
- Social Determinants of Health assessments.
7. Ensure Accurate Billing and Program Compliance
By delivering value-based care through CCM, your practice unlocks additional recurring revenue opportunities. To maximize reimbursements, your clinical staff must possess a thorough understanding of CCM billing rules, service requirements, and relevant CPT codes.
CCM services are billed monthly based on non-face-to-face care coordination provided by your staff or your CCM partner’s team. The specific CPT codes billed vary depending on the complexity of care and the total time spent on care coordination. Maintaining meticulous records of all CCM care coordination services is crucial for program compliance.
Accurate billing is often a complex and time-consuming aspect of CCM implementation. ChartSpan’s RapidBill technology simplifies this process by enabling easy review and billing of CCM services each month. We compile necessary documentation and provide the appropriate CPT codes for your review and submission to CMS, streamlining revenue integration into your practice.
8. Establish Clinical Alignment and Communication Protocols
Effective clinical alignment is essential for smooth and reliable CCM program operations. When partnering with a CCM vendor, clearly define protocols for tasks such as:
- Extracting C-CDAs to gather patient eligibility data.
- Initiating notifications regarding specific patient needs.
- Triaging incoming calls and escalating urgent needs or emergencies.
A strong CCM partnership ensures a consistent schedule for C-CDA extraction and patient list review.
Establish clear communication frequency and methods for clinical notifications between your practice and your CCM partner. Notifications should be bidirectional, allowing your practice to also send notifications to your partner regarding specific patient concerns or conditions.
Develop a robust protocol for handling triage calls. Your CCM partner should operate a fully staffed 24/7 care line with a defined triage process. In emergencies, CCM nurses should immediately contact 911 and subsequently notify your practice about the event and patient status. Establish preferred channels for receiving urgent notifications to facilitate timely follow-up by your providers.
9. Define Measurable Success Metrics and Goals
To gauge CCM program effectiveness, practices must establish practical and measurable success goals. These metrics should encompass patient enrollment rates, patient retention, patient satisfaction, and progress toward individualized care plan goals. You may also set goals related to improving practice quality scores, such as those under CMS’s Merit-based Incentive Payment System (MIPS) or the Overall Hospital Star Rating system.
Define success metrics before CCM implementation, regularly assess progress, and be prepared to adjust strategies as needed.
CCM partners can assist in setting realistic, data-driven goals. For instance, ChartSpan targets a 45% patient enrollment rate, implementing a gradual enrollment ramp-up over the first six months and continuously refining enrollment and education methods.
ChartSpan’s clinical team sets internal goals for care plan development within the first two months of enrollment and for conducting clinical and medication adherence assessments for all engaged patients. We collaborate with practices to establish additional customized goals aligned with their specific objectives.
10. Partner with ChartSpan to Optimize CCM Program Outcomes
CCM program implementation is often complex and resource-intensive. Many practices encounter workflow disruptions, increased administrative burden, and the need for additional staffing and infrastructure investments when managing CCM in-house. However, partnering with a specialized CCM company alleviates these challenges, enabling you to focus on delivering exceptional care to chronically ill patients while securing consistent reimbursements.
ChartSpan provides a comprehensive suite of services to ensure seamless CCM program operation. Our specialists manage patient eligibility verification, outreach, and enrollment. Our compassionate care managers serve as an extension of your practice, providing monthly patient calls and care coordination. Our 24/7/365 care line, staffed by skilled care coordinators and nurses, addresses patient inquiries and manages emergencies effectively. RapidBill simplifies and streamlines the billing process.
Additionally, ChartSpan provides complimentary quality improvement specialists to help enhance your quality scores, and our team manages staff onboarding and ongoing CCM education.
ChartSpan’s 6-Step Approach to CCM Success:
- Onboard: Comprehensive CCM training for your entire staff.
- Identify & Enroll: Patient eligibility identification and enrollment management with your approval.
- Engage: Proactive patient outreach and engagement in their care management journey.
- Intervene: Care coordination and preventive care facilitation to drive positive clinical outcomes.
- Measure: Quality measure tracking, performance metric monitoring, and compliance support.
- Bill: Streamlined billing through our proprietary RapidBill technology for easy CMS submission.
Discover How ChartSpan Can Facilitate Your CCM Program Launch
Implementing CCM doesn’t have to be a daunting undertaking. By partnering with a full-service CCM provider like ChartSpan, your practice can realize the transformative benefits of CCM without overburdening your staff. Contact us today to explore how ChartSpan’s CCM program can positively impact your practice’s care delivery and financial health.
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