Extend Your Reach: Care Coordination for Chronic Care Patients

Healthwise Care Coordination Team

Editor’s note: In these posts, we’ll explore six steps for developing a care coordination program that increases revenue, cuts costs, and enhances the quality of patient care. In this post, we’ll look at five steps to implement chronic care management into your care coordination program.

When patients have multiple chronic conditions, ensuring continuity of care can be especially challenging. We’ve spent some time in this blog series looking at how care coordination is a beneficial practice for patients, physicians, and organizations. Considering that chronic diseases and conditions are among the most common, expensive, and preventable health problems in the US, it’s not surprising that care coordination programs can help with chronic care management (CCM) as well.

In 2015, Medicare began paying physician practices for select CCM services, but almost half of health care organizations lack a formal CCM program, leaving critical reimbursement dollars on the table.

So, what is CCM, and what’s included in it? It’s the services that are not face-to-face provided to Medicare beneficiaries who have two or more significant chronic conditions. These are services for conditions that likely require ongoing adjustments, monitoring, and cross-clinical coordination. CCM includes electronic and phone communication with the patient, medication management, and 24/7 accessibility to patients and other care providers. Creating and revising electronic care plans is also a key component of CCM.

Here are five steps to implementing a CCM to increase the reach of your care coordination program:

One: Ensure EHR system certification and capabilities.

It may feel like yesterday, but 2011 is as far back as you can go for certification of your EHR system. If your system is older than that, you won’t be able to bill with the chronic care management code.

Your EHR needs to be able to support documentation of team care and care outside of an office visit. You’ll need to be able to electronically capture clinical data and provide patients with electronic copies of health information and patient education.

Two: Identify patients.

Providers can bill for CCM for Medicare patients who have been diagnosed with two or more chronic conditions that are expected to last a year or more. Search EHR records to identify patients who qualify. Here’s a list of examples of chronic conditions:

  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Cancer
  • Cardiovascular disease
  • Chronic obstructive pulmonary disease (COPD)
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases like HIV/AIDS

Three: Invite patients to participate.

To participate in CCM, patients must consent in writing. They also have to authorize that you can share their health records with other providers. It’s important to note that providers should explain to patients how the CCM program works—what is the patient’s responsibility, how to make payments, and how to stop participating if necessary.

Successful CCM requires regular monitoring of the patient’s health status and frequent communication and information sharing by the patient’s health care providers, which makes CCM a natural fit for a care coordination program.

Four: Build a care plan.

Each CCM participant needs a patient-centered care plan that includes an assessment of the patient’s medical, functional, and psychosocial needs. Assessments, preventive care recommendations, medication reconciliation, and self-management of medications should all be addressed in the care plan. And it needs to be consistent with the patient’s choices and values.

Five: Document.

Remember to document the patient consent and the care plan in the patient’s EHR. Managing care transitions is an important part of CCM and should cover referrals, follow-up with other clinicians or hospitals, patient education, and coordination with community and home-based services who support the patient. These interactions are recorded in the patient’s EHR.

Adding CCM to your care coordination program is something that can help you reach patients who have a real need for things like medication monitoring, frequent contact, and modifications to treatment paths. Many best practices we see in care coordination programs are a logical fit for chronic care management, too.

Read our eBook, The State of Care Coordination: 6 Illuminating Strategies You Should Know, for more information on best practices in care coordination to facilitate change.