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Chronic Care Management

Key Considerations for Starting a Chronic Care Management Program

July 6th, 2021 | 7 min. read



Content Team

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Here you are, you’ve done it.

You've decided to start a Chronic Care Management (CCM) program. 

The progress feels real — another innovative step forward for your practice. So, what now?

You may ask:

  • Should I administer my own program or outsource it?
  • Who on my team will drive the program and lead patient interactions?
  • What technology will be key to its success?
  • Will there be enough patient activity to amount to billable time?
  • Who of my patient base will indeed take part, and how so?

These questions are a reflection of your intelligence. Not barriers or cynicism.

As a medical professional, you usually create realistic expectations for your patients. It’s sensible to apply the same logic in this instance, too.

When discussing the potential of CCM, it is common to absorb key talking points. Or internalize flashy statistics. It is less common to think of the requirements for success. 

We work with more than 600 clinics and physician practices. Our true service is to provide intuitive, cost-effective care management software. But, based on client feedback and questions, we understand the common missteps that plague CCM programs. 

In this article, we’ll answer the questions posed above. So, hold your head high, and be ready to author that winning case study.

Should I Insource or Outsource My Program?

As we’ve detailed before, implementing a CCM program requires a plan. It should include the actual logistics of the project, as well as the necessary staff. 

What Insourcing Your Program Would Look Like

Initially, it might be tempting to lean on your current team. You already work with them, know their capabilities, and have established trust.

In some cases, insourcing your CCM effort could make sense. If your staff has the capacity. This strategy enables close oversight and direct relationships with patients.

We recommend at least one designated care manager.

Guided by the practitioner, the care manager drives the entire CCM program. They perform monthly patient engagement, coordinate medical treatment, develop care plans, and advocate for patients. The work hours required for this role could be extensive.  

The Centers for Medicare and Medicaid Services (CMS) requires a practitioner to fill this role. Or one of the following resources:

  • Registered Nurse
  • Licensed Practical Nurse
  • Certified Medical Assistant
  • Health Coaches (in some areas)

Most likely, the job will go to one of the above options. In the event these team members are already occupied, a new hire could be necessary.

Though that’s another expense, a dedicated resource encourages staff buy-in. If your staff engages, it will promote the effort and drive positive results. 

As one Florida health clinic found, a top-down commitment from all stakeholders led to brisk program growth. Several hundred patients quickly enrolled.

What Outsourcing Your Program Would Look Like

That said, investment in a full-service, outside CCM vendor also presents an opportunity.

While this option may come with a higher cost, as you’ll pay for expansive, expert resources, there is higher enrollment potential. A broader team will be available to serve a larger patient population.

This option may make sense for a robust practice, or an organization that lacks the resources to manage a CCM program.

Either way, keep in mind: A successful CCM program requires ample investment to deliver a valuable service to your patients.

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Electronic Health Records Won’t Do The Job (Alone)

EHRs document patient information and data, as well as accurately bill insurers. However, they lack key capabilities for care management programs. They are missing software features, such as guided workflows, symptom tracking, and provider instructions.

These tools support care managers in their daily interactions with patients. They promote quality service that will encourage long-term enrollment.

As well, health organizations need operational efficiency. The profitability of a CCM program depends on effective time management. Medicare requires at least 20 minutes of non-face-to-face patient engagement monthly to be billable. These interactions (and their corresponding time) must exist on file, in case of an audit.

EHRs cannot record this information. They cannot collect and show a patient’s CCM history or share care plans, either. Effective care coordination software does. By working with, rather than replacing, a practice’s EHR, this software fills the gaps. 

Again, like dedicated personnel, infrastructure is crucial to CCM’s success. It’s an extra cost, but if you manage the program properly, Medicare reimbursements will outweigh the expense. In the long run, your practice and patients are likely to benefit.

Establishing A Care Plan Takes Time.

On average, a care manager will spend between 20 and 40 minutes preparing a patient’s initial care plan. Subsequent updates can accumulate in additional 20-minute increments per month.

Care management software guides this process — simplifying it through a preformatted questionnaire. Yet, collecting a patient’s intimate, and sometimes intricate, health information is nothing to rush. And sometimes the patient is talkative! 

Creating a personal care plan commences a person’s participation in a CCM program. Once a patient consents and enrolls, a care manager inquires about their needs based on chronic conditions. They draft a roadmap to inform ongoing treatment.

This relationship between practice liaison and patient develops monthly. Through a phone call or a telehealth appointment. Aside from the care plan, care managers spend time analyzing a patient’s medical chart, refilling prescriptions, or offering specialist referrals. All of which count toward billable CCM time.

This is all to say: CCM can be a time-consuming endeavor, especially if you’re expecting to enroll hundreds of patients.

So, it’s wise to bake this assumption into your initial program management strategy. Doing so will assure your practice does not bite off more than it can chew.

But Will I Actually Enroll Hundreds of Patients?

Medicare likes to tout how many Americans live with two or more chronic conditions. According to CMS, approximately one in four adults, including 70% of Medicare beneficiaries, have two or more chronic conditions.

If you ask the National Health Council, nearly 133 million people in the United States live with at least one of these conditions or about half of all adults.

Medicare introduced CCM in 2015 as a preventative, cost-cutting method to treat these illnesses. And it’s made a point to signal that the initiative isn’t going anywhere anytime soon.

Healthcare providers see plenty of potentials, for themselves and their patients, in this program. It is possible that an even greater share of the U.S. population will endure such conditions in the future.

But, does a large target audience actually equate to high CCM enrollment rates? In truth, no.

We’ve found that a well-managed program will net about a 30 to 40% participation rate, based on a provider’s promotion efforts.

This information may humble your expectations, but it should serve as a reminder. Yes, CCM participation rates have plenty of room to increase, but that’s exactly the point.

There’s plenty of room to scale.

CCM will see regular implementation in the years to come. Medicare Part B already provides at least 80% coverage, with no sign of reversing course.

Other insurers are starting to acknowledge CCM as a benefit, too.

And private companies are developing innovative tools to further normalize the program.

You may desire high enrollment, but a small patient population is less to manage. You can effectively introduce your program and incorporate it into your broader practice. Time will lead to growth. 

Software for Chronic Disease Management

Digital software solutions are available to help your practice embrace integrated care management for chronic diseases.

At ThoroughCare, we’ve designed our integrated care coordination software for easy clinical use. It relies on an intuitive interface that allows you and your team to engage patients through multiple care management, telehealth, and wellness programs. 

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