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The Complete Chronic Care Management Guide

Maximize Reimbursements without Sacrificing Care

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The Basics of Chronic Care Management

The term “Chronic Care Management” might be new to some, but the concept of managing patients with chronic conditions is not. Chronic conditions are defined as any condition that is persistent or long-lasting, typically for more than 3 months.  Chronic conditions usually cannot be cured or prevented by medicines or vaccines. However, most patients with chronic conditions can live long and happy lives if their chronic conditions are well-managed. 

Chronic Care Management

Examples of the most common Chronic Conditions in the United States include:
  • Diabetes
  • High Blood Pressure
  • Hypertension
  • Heart Disease
  • Heart Failure
  • COPD
  • Asthma
  • Plus many others...

How Are Chronic Conditions Managed?

Patients with chronic conditions can be prescribed medications, diet changes, exercise programs and other treatments to effectively manage these conditions.  Unfortunately, if these conditions are not properly managed, patients may end up in the emergency department or admitted to the hospital. In the worst-case scenario, patients could have serious health risks or die from unmanaged chronic conditions.

Some may think that chronic care management is simply caring for someone with chronic conditions but there’s much more to it.  In a general sense, chronic care management encompasses any care provided by healthcare professionals to patients with chronic diseases and health conditions.  The goal is to ensure that the patient achieves a better quality of life while living with these conditions. A better quality of life can include: 

  • Reduced pain
  • Increased mobility
  • Better sleep
  • Reduced stress
  • Increased physical condition (flexibility, endurance, strength, etc.)
  • Return to previous activities, hobbies, or work.

While these improvements can be achieved by various means, the most common methods are interventions and therapies. This is where the Centers for Medicare & Medicaid Services’ (CMS) CPT Code 99490 comes in.


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Code 99490

Since January 2015, CPT Code 99490 has helped promote top-quality CCM services by paying providers to deliver non-face-to-face care to Medicare patients. Specifically, it allows eligible practitioners and suppliers to bill $42 for at least 20 minutes of non-in-person staff time per month for patients who meet specific criteria.

Physician practices can bill CMS directly for these services and outsource them, at their discretion, to third-party specialists.  The benefits of this are twofold in that CCM services can help patients live a healthier lifestyle and avoid unnecessary hospitalizations, while healthcare providers themselves can generate revenue from CMS.

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Best Practices for Chronic Care Management 2019

Chronic Care Management provides patients with a better quality of life while increasing your practices annual income. With so much at stake, it is imperative to stay on top of the latest trends. We have everything you need to know about Chronic Care Management best practices in 2019 outlined for you right here.

Promote Wellness and Preventative Programs

The best way to manage a chronic condition is to diagnose it early through preventive wellness programs (such as an Annual Wellness Visit, frequent labs, and blood testing).  Programs like the Annual Wellness Visit are covered 100% and made available at no cost to the patient. The Annual Wellness Visit begins with a thorough Health Risk Assessment (HRA) that includes a comprehensive review of the following:


  • Family Medical History
  • Past surgeries and hospitalizations
  • Devices and Suppliers
  • Medications and Allergies
  • Drug, Alcohol and Substance abuse screening
  • History and risk assessment for Falls
  • Activities of Daily Living Review
  • Review of preventive tests, vaccines, and screeners

Annual Wellness Visit

These Medicare wellness visits are offered free of charge to your patients each year. Unfortunately, many providers skip this because they are too confusing. Get the clarity you need by visiting our AWV page. 

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Participate in a Value-Based Payment Program

 Value-Based Payment Programs (VBPs) provide financial incentives to healthcare providers for the quality of care provided to people with Medicare. These programs, including those introduced through the Medicare Access and CHIP Reauthorization Act (MACRA) are part of the CMS quality strategy to reform the healthcare payment and delivery systems, which focus on improved clinical outcomes (at both individual and population levels), demonstrated operational efficiency, promotion of interoperability (more below) and reduced cost of care.  

Achieving the goals outlined above requires healthcare providers to assess and introduce key components to providing comprehensive quality care such as delivery, care management, and care coordination across a patient’s care team. These components define the foundation for practices to meet expected outcomes and performance required by VBPs. In addition, practices require an infrastructure, including predictive modeling and risk stratification capabilities, that supports population health management.

Examples of Value-Based Programs include:

  • Medicare Shared Savings Programs (administered by Accountable Care Organizations)
  • Merit Improvement Payment System (MIPS)
  • Comprehensive Primary Care Plus (CPC+)
  • Patient-Centered Medical Home and Health Home Models

Providers participating in these programs are seeing significant results according to Privis Health, “A whopping 80% of payers report improvements in care quality with through value-based programs, while 73% report improved patient engagement.

These promising statistics make it unsurprising that fee-for-service models now only make up 37.2% of reimbursements. By 2020, that number is expected to dip below 26%.”

Providers that offer additional convenient programs such as comprehensive patient dashboards, minute clinics without co-pays, and primary care physicians (PCPs) located in shopping-centers will find that they are rewarded by improved consumer health—and consumer loyalty.

Support a Data-Driven Approach to Care Coordination and Management

Effective Care Management is driven by data.  All of the value-based programs listed above require providers to report on regulated clinical processes and outcomes.  To demonstrate overall improvement, providers must report to payers using specific metrics, which must be quantifiable. Providers track and report on everything from readmissions to population health, and patient engagement to relapses in illness.

Because of these requirements, healthcare organizations will begin to focus more on gathering, protecting, and analyzing data.  Providers should make sure their EHR solution is properly configured to identify and track quality metrics.

Improve Data Interoperability

As described above, data is extremely important in managing chronic patients, particularly in value-based care.  Unfortunately, because the data comes from so many various groups and organizations, it is often located within multiple systems, some of which are disconnected.  

Fragmented data can lead to a variety of problems such as gaps in care, no or limited access to patients historical data or an inability to identify patients health trends. For chronic care to be effective, it is integral that providers have access to their patient’s historical data. Without this data, providers will not be able to locate a patient’s health trends, avoid gaps of care, or ensure smooth transitions of care.

Providers participating in care management programs like CCM are incentivized to share data with other providers through a combination of data exchange and care coordination across the patient care team.

Implement Integrated or Wearable Devices

Integrated or wearable devices allow providers to monitor a patient with chronic conditions while decreasing the costs associated with care. With wearables, you can stay connected with patients by tracking sleep, calories burned, heart rate, and more.  They can be configured to send out a 911 call or to share its data with healthcare providers in real time. These features enable these providers to proactively address potentially dangerous situations (such as weight, blood pressure, blood glucose), with adequate time to resolve them.

While remote devices can provide a better experience to patients, CMS will reimburse providers for monitoring the data from integrated devices.  Providers can supply these devices to their patients and receive full reimbursement from CMS. This is an extremely popular way to encourage patients to participate in sharing this data.


Types of integrated/wearable devices include:

  • Digital Scales
  • Blood pressure monitors
  • Glucometers
  • Pulse oximeter
  • Activity Trackers (e.g Fitbit, Apple Watch, etc.)
  • Other devices that can connect to WiFi that have the capability to transmit readings to the care team and provider.

Ensure your organization is on top of what patients need and are looking for this year by implementing these best practices in 2019!

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Chronic Care Management Software Cost (Factors & Value)

Current estimates show more than 115 million adults are living with at least one chronic health condition.

This figure is significant for healthcare providers. In fact, 99% of Medicare spending is allocated to patients living with chronic conditions like fibromyalgia, diabetes, multiple sclerosis, and hypertension.

So, how can practitioners maximize reimbursements without sacrificing patient care? A comprehensive chronic care management (CCM) program is the answer. Specifically, this post will explore the cost and benefits of CCM software.

What Is Chronic Care Management Software?

CCM software is a comprehensive way for healthcare providers to simplify their chronic care management program and ease the burden of caring for patients. It helps physicians and clinical staff manage chronically-ill patients more effectively, promotes patient and practitioner satisfaction, and allows healthcare professionals to bill CMS for services they might have previously offered for free.

Specifically, CCM software allows users to:

  • Create HIPAA-compliant dashboards for multiple patients or providers
  • Report on CCM minutes
  • Create chronic care plans or reports
  • Manage billing and easily submit 99490 claims
  • Download summaries and upload them to their Electronic Health Records (EHR)

Platforms are secure, can accommodate unlimited users and patients, and include tech support via phone and email. Ultimately, CCM software will allow your practice to deliver seamless chronic care management services and make the most of Code 99490.

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Factors That Contribute to CCM Software Rates

There are several factors that can affect the cost of CCM software. This section will outline some information to consider, including the items that will affect your startup and maintenance costs. It’s also worth noting that CCM software can be tailored or combined with other plans to suit your exact needs.

The main indicators that affect pricing are the number of practitioners using the software and the level of reporting required for your practice.

  • Overall pricing is tailored to reflect:
    • The size of your practice
    • The number of Medicare patients you see
    • The goals of your programs
  • The cost of running and maintaining the software is determined by:
    • How patients will be billed
    • Your recurring payment schedule
    • Your practitioner payment schedule 
  • Your current hosting setup and structure can raise or lower your startup costs as well. Healthcare practitioners may have the option to either import data and set up their own site using CCM software or subscribe to a plan that will oversee everything on their behalf. The latter generally includes HIPAA-compliant hosting, live technical support, and ongoing training.
  • In addition to CCM, many software providers offer other solutions that may be of interest, including:
    • Annual Wellness Visits (AWV) 
    • Integrated Behavioral Health (BHI) 
    • Transitional Care Management (TCM) 
While adding on other solutions will increase the total cost of your CCM software solution, it can save you money and frustration in the long run. Packaging your management solutions in one place presents a frictionless experience for healthcare providers and clinical staff.

Hidden Costs

Most CCM software solutions solve healthcare management pain points from start to finish. There is an onboarding process required for new practices using chronic care management software, which may affect the bandwidth of your IT team and any other staff who will be using the software on a daily basis. This is certainly something to plan for before you get started.

Furthermore, a dedicated employee may need to manage the software in the long term, fielding support issues and any other problems that end users might encounter. Before committing to a software solution—depending on the size of your practice—you might consider hiring or reassigning someone to fill this position.

Savings Associated with CCM

Time savings. Higher patient and healthcare provider satisfaction. Less turnover. These are just some of the ways CCM software can save you money. Groups of all sizes can benefit from a CCM software solution, from one-person practices to large ACOs and health systems.

While it would be challenging to determine exactly how much money chronic care management software can save your practice, one thing is certain: Technology focused on addressing CCM services and requirements can simplify some of even the most complicated tasks, delivering value to both patients and healthcare providers.

The Annals of Internal Medicine revealed in 2015 that healthcare practices billing Code 99490 for non-physician-provided CCM services (that is, services provided by registered nurses and other medical staff) would experience an annual practice revenue increase of $75,000 or higher if at least 50% of eligible patients were enrolled. That’s no small sum.

Ultimately, a blend of CCM software and value-based care programs is slated to provide scalable growth for your practice. Since value-based care is fueled by data, providers must report and analyze quantifiable metrics to get paid for the CCM services they deliver—and chronic care management software can help accommodate the tracking and data analysis tools practitioners need.

Our experience with ThoroughCare has been absolutely wonderful. They provide superior customer service. Since starting the Chronic Care Management program through their platform, we have made many positive impacts. We have increased our quality measure scores and reduced hospital readmits, resulting in a decrease in overall spend.

Sabrina Martin, Director of Provider Network Management - National ACO

The Takeaway On Chronic Care Management Software

In closing, those who would benefit from chronic care management services do not have to be a source of pain or expense for your practice. CCM software can help patients with chronic medical conditions access primary care services, all while lessening the financial strain on the healthcare system and streamlining chronic care management services for providers.

With the new codes implemented by CMS, healthcare providers everywhere can capitalize on this incentive. All it takes is the proper tools, which CCM software can provide for a reasonable investment.

If you have questions or further insights into chronic care management software, please share your thoughts in the comments below. You can also review the specifics surrounding CCM services and Code 99490 here.

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Chronic Care Model Components You Should Know

Developed in the mid-1990s, the Chronic Care Model combines research and theories surrounding chronic illness management. Its primary goal is to help patients with chronic illnesses in their effort to improve or maintain their conditions.

In addition, the Chronic Care Model promotes recovery and chronic disease management in a way that’s efficient and effective for private practices. Another objective is to help healthcare providers leverage a crucial resource and successfully treat more patients. 


What Is the Chronic Care Model?

The the Chronic Care Model is a multifaceted, evidence-based framework for enhancing care delivery. It involves the identification of essential healthcare system components, which can be adjusted to support high-quality, patient-centered chronic disease management.

Put simply, the Chronic Care Model offers a systematic approach to practice transformation. It’s meant to provide a foundation for healthcare practitioners so they can perform their jobs more effectively.

Components of the Chronic Care Model

The Chronic Care Model consists of six key components. These categories are as follows:

  1. Health Systems & Organizational Support
    Includes culture, organizations, and mechanisms to promote safe, high-quality care.

    This category addresses both the culture and the structure of the healthcare practice. A successful chronic care management practice features a culture where managing chronic conditions is of the utmost importance. As such, leadership must be committed and involved in the Chronic Care Model, yet they must also be open to change. That way they can continually improve the quality of the care they deliver.

    Accordingly, this component of the Chronic Care Model indicates that practices must give incentives to providers and patients, with the aim of improving care overall.

    In turn, practice leaders must set healthcare team expectations and make quality a top priority. They can fulfill this role by providing resources to support chronic care and practice improvement programs.

  2. Decision Support
    Evidence-based and rooted in patient needs and preferences.

    This category gives practices a method for increasing access to evidence-based guidelines. Moreover, practices will learn to access a higher number of specialists for collaboration purposes.

    So, decision support could mean researching literature and studying clinical information systems. Or, as described above, it could mean accessing other providers who have implemented the Chronic Care Model, in order to collaborate on the best possible patient treatment plans.

  3. Clinical Information Systems
    Meant to organize patient, population, and provider data in a clear and cohesive way.

    These systems are put in place to organize data and describe the health of the population, all while ensuring practices are equipped to deliver efficient and effective care.

    It’s worth noting that clinical information systems should provide information about individual patients, as well as data involving groups (or populations) of patients. In this category, providers should not hesitate to be thorough in the way they collect and analyze data.

  4. Patient Self-Management Support
    Developed for patients to manage their health and medical care.

    The main goal of patient self-management support is to empower and prepare patients with chronic conditions so they can manage their own health and healthcare moving forward.

    Focusing on patient-centered interventions, including one or more of the following:

    • Tailored education resources
    • Skills training
    • Psychosocial support
    • Patient-provider collaboration (in order to define challenges, set priorities, establish goals, identify barriers, develop treatment plans, and solve problems)

  5. Community Resources
    Includes the mobilization of patient resources.

    This component is closely related to the previous one. The reason for this is that the Chronic Care Model emphasizes connections within the community. These connections may relate to peer support, care coordination, and community-based interventions.

    It’s important to note that while community and practice relationships are important for all patients, they are especially critical for elderly, low-income, and underserved populations.

  6. Delivery System Design
    Created for clinical care and self-management support, including team care.

    Team care blends the skills of primary care providers and other clinical staff with those of patients and their family members, culminating in a comprehensive lifetime chronic disease management program.

    Similarly, delivery system design addresses the composition and function of the practice’s team of healthcare providers, as well as the organization of visits and the management of follow-up care.

    The delivery of effective, efficient clinical care—through the appropriate use of all team members, planned patient interactions, frequent follow-ups, and case management—is an essential part of this component.

In summary, the above components of the Chronic Care Model focus on patient safety, cultural competency, care coordination, community policies, and case management. Each Chronic Care Model component is meant to help drive change in your healthcare practice and better serve patients facing chronic conditions.


The Chronic Care Model has been used in a variety of healthcare settings. It was designed to guide systematic and individual improvement in chronic illness care, including diabetes and other conditions.

In the scientific community, studies have shown the effectiveness of chronic care intervention and related outcomes stemming from the CCM.

And as you can see, the Chronic Care Model—as it relates to patient care—is multifaceted. This means organizing and setting up systems to contain and manage data can be daunting.

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Complex CCM

Like chronic care management, complex chronic care management includes the healthcare delivered to patients with chronic conditions such as diabetes, hypertension, and multiple sclerosis. Unlike CCM, complex CCM includes extended care coordination for particularly complex patients.

Complex CCM Billing Codes & Requirments

According to the Centers for Medicare and Medicaid Services (CMS), complex CCM is billed under CPT Code 99487 and meets the following requirements:

  • The patient has been diagnosed with two or more chronic conditions that are expected to last at least 12 months or until their death.
  • These chronic conditions put the patient at substantial risk of death, functional decline, or acute exacerbation or decompensation (organ failure).
  • The physician or another qualified healthcare provider has established or significantly revised the patient’s care plan. 
  • The patient receives 60 minutes of clinical staff time per calendar month—either with a physician or with another qualified healthcare provider. Complex CCM services of less than 60 minutes per calendar month are not reported separately.

Complex CCM can also be billed under CPT Code 99489:

  • This includes every additional 30 minutes of clinical staff time per calendar month. Code 99489 must be reported separately from any primary procedures.

CCM Billing Codes & Requirments

Let’s quickly review the definition of chronic care management. According to CMS, non-complex CCM is billed under CPT Code 99490 and meets the following requirements:

  • The patient has been diagnosed with two or more chronic conditions expected to last at least 12 months or until their death.
  • These chronic conditions put the patient at substantial risk of death, functional decline, or acute exacerbation or decompensation (organ failure).
  • The physician or another qualified healthcare provider has established, implemented, revised, or monitored the patient’s care plan. 
  • The patient receives at least 20 minutes of clinical staff time each month—facilitated by either a physician or another qualified healthcare provider. CCM services of less than 20 minutes per month are not reported separately.

In addition to physicians, qualified healthcare providers include clinical nurse specialists, nurse practitioners, physician assistants, and certified nurse midwives. Non-physician practitioners must be authorized to deliver CCM services in their state.

Key Differences Between CCM & Complex CCM

CCM and complex CCM services share similar
elements. The main differences lie in the:

  • Amount of clinical staff time provided
    •  Complex CCM requires at least 60 minutes of clinical staff time.
    • CCM requires at least 20 minutes of clinical staff time.
  • Extent of care planning involved 
    • Complex CCM includes the development or significant revision of the care plan.
    • With CCM the comprehensive care plan is already established, implemented, revised, or monitored.
  • Complexity of medical decision-making 
    • Complex CCM involves moderate to high-complexity medical decision-making.
    • CCM does not require the same level of high-complexity medical decision-making.
  • Scope of work and involvement of billing staff
    • Complex CCM billing staff will generally spend more time on complex CCM services.
    • CCM billing staff, in general, will spend less time on CCM

Consider the following CMS chronic care management overview for more information.

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What Do These Differences Mean for Your Practice?

The differences between complex and non-complex chronic care management will affect both patient eligibility and which professionals can deliver the services. Here are the specifics:

  • Patient eligibility
    Patients are not permitted to receive both complex CCM and CCM services in the same calendar month. The billing professional can report one complex CCM service or one non-complex CCM service per patient per service period.
  • Authority to deliver services
    According to Medicare’s Physician Fee Schedule (PFS), complex CCM codes fall under general supervision. This means the billing professional does not need to personally deliver the health services. Rather, any qualified, authorized practitioner may do so.

Aside from the items described above, CCM and complex CCM will remain more or less the same for your practice.

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Simplifying CCM in Your Practice

CCM can feel daunting to implement in your practice.  However, you can create a system that will simplify CCM to set your practice up for success. In this post, we go over strategies and resources to empower your practice.  

Strategies for Simplifying CCM and Complex CCM

When it comes to simplifying CCM you will want to look internally at your administrative team and your practice as a whole. Here are our key recommendations for success:

An All-Star Administrative Team

Your administrative team will have a direct effect on simplifying this process. The more knowledgeable and dependable your staff is the easier it will be to implement these services. An all-star administrative team is:

  • Trained and knowledgeable in CCM best practices.
  • Equipped to manage numerous patient check-ins and provide long-term care plans.
  • Identify patients who have faced two or more chronic health issues in the last 12 months and prioritize their care plans.
  • Schedule patients for regular appointments.
  • File claims and manages payments.

 General Practice Improvements

You can streamline your program by implementing the following at your practice:

  • Developing processes for ongoing implementation 
    CCM providers must offer non-face-to-face outreach care, including 20 minutes of care by phone, email, or text each month. Outreach may include medication management, following up after a hospital discharge, or sharing the patient care plan.
  • Filing claims on a monthly basis
    Reimbursement claims should be filed every month. The fee requirements may seem confusing at first, but there are solutions available to ensure a smooth process.
  • Frequently monitoring your CCM program
    It’s far too easy to start out involved and later neglect your CCM program. Avoid taking a “set it and forget it” approach, and check in with your program from time to time. Make sure you’re enrolling new patients and engaging with your audience. 
  • Searching for commercial payer reimbursement opportunities

The above strategies are specific to CMS. However, commercial payers often have less rigid requirements (and provide higher payments) than Medicare. Check in with these payers to see what they can offer.

ThoroughCare is by far the most user-friendly software application that captures all ingredients of Chronic Care Management. We see this as a great value for our enrolled patients. ThoroughCare has made this seemingly complicated task very easy for patients and providers alike.

Eugene Sangmuah, MD Matthews Internal Medicine

Resources for Simplifying CCM

When it comes to simplifying your CCM program, technology is a great resource. CCM software can lighten the workload of your administrative team and help with tasks such as:

  • Structured reporting
  • Accountability and alignment with the care plan
  • Patient communication

Wearable devices are highly beneficial as well. By continuously monitoring the patient, they will reduce the number of required in-person visits and save healthcare providers precious time. 

Implementing A Program

CCM programs are inherently versatile and can be tailored to meet your practice’s needs. Accordingly, you have the option to either outsource your CCM services or implement a program in-house. Here is what you can expect with each option so you can identify which will be the easiest/ best fit for your practice. 

Outsourcing Your CCM program

Outsourcing is arguably the most simplistic option for software implementation. When outsourcing your program, all third-party staff will be fully trained in CCM. You will have to pay more for these professionals’ expertise, but investing in a proven solution can make you more money in the long term.  

What you can expect with outsourcing: 

  • Greater accuracy & efficiency
    The third-party team will focus entirely on ensuring a comprehensive, frictionless CCM program. 
  • Higher profitability
    Third-party teams and software solutions like ThoroughCare will reduce your risk of errors. This, along with the boost in staff productivity, will save your practice money and increase profits.
  • More time & energy
    Your CCM program will require training no matter your approach. That said, hiring a third-party team will reduce practitioner stress and save you time in the long run.

In-house Implementation of Your CCM program  

Taking this on in-house will require more work upfront. However, it is possible to tackle if you are aware of what to expect.

What you can expect with an in-house implementation:

  • Training
    Developing and implementing your own program will require extensive training and education. Your healthcare practitioners, IT specialists, and other staff will need to customize your CCM system, and then be on-boarded.

    Once you complete this training, however, you’ll be on a solid track.
  • No monthly Free
    You won’t have to pay a monthly retainer fee to a third party. 

Ultimately, when deciding between outsourcing your program and developing it in-house, it all comes down to the amount of time, funding, and staff at your disposal.

It’s essential to have a game plan, as you are providing a specialty service. Plus, a complex CCM program requires a substantial time commitment, ongoing education, and heavy administration to ensure compliance and accuracy.

 Fortunately, there are a number of CCM software solutions you can adopt, either in-house or with help from a third party. These solutions are well worth the investment and can be tailored to your exact needs.

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Creating a CCM Dashboard (Benefits & Guide)

Are you thinking of building a chronic care management (CCM) dashboard? If so, you’ll need some foundational information to get started.

In this article, you will learn what a CCM dashboard is and why having one will positively impact your practice. 

You will also review what goes into creating your own CCM dashboard, along with the resources you can leverage if the task becomes too daunting.

What Is a CCM Dashboard?

A CCM dashboard is a software platform designed to help clinicians and staff coordinate care for patients facing multiple chronic conditions. These conditions may include diabetes, hypertension, lupus, and more.


The dashboard is available around the clock and features the following:

  • Healthcare metrics and KPIs
  • Time tracking
  • Reporting
  • Billing
  • Clinician and patient accountability

It’s meant to promote clear patient-practitioner communication, along with greater organization and efficiency.

Benefits Of A Dashboard

The benefits of a chronic care management dashboard are extensive. Specifically, a CCM dashboard will allow you to:

  • Measure healthcare outcomes.
    These outcomes include mortality, readmissions, patient experience, and the efficient use of medical imaging. Safety, effectiveness, and timeliness of care are key outcomes as well.

  • Gain quick and actionable insights.
    Dashboards allow users to easily find answers to provider questions. They represent a comprehensive solution that offers:
  • A consolidated, visual view.
    CCM dashboards make it easier for healthcare providers to track patient well-being. For instance, your dashboard can be color-coded, which means you won’t have to manually analyze trends.
  • Awareness of population health trends.
    Dashboards offer clinicians and care teams a holistic view of patient populations, allowing them to make valuable, timely, and strategic health decisions.
  • A simple way to monitor variations.
    By using dashboards, care providers can narrow down the reasons for the patient’s health challenges, pinpoint the most effective treatments, and reduce variations.
  • Seamless efficiency and growth tracking.
    With a CCM dashboard, healthcare providers can monitor their growth measures and uncover the outcomes of the improvements they drove.

These are just some of the reasons to start using a CCM dashboard.

Where to Begin When Creating Your Own CCM Dashboard

If you are not sold on the idea of using a software solution, you will need to create your own CCM dashboard.

Here’s what you should do when tackling this project: 

  • Start with a spreadsheet.
    A spreadsheet will allow you and your team to visualize trends and track big data. 
  • Visualize trends
    Sifting through raw data can be challenging—especially for team members who aren’t used to picking up on patterns. As such, presenting the data in a clear and visually impactful way can make all the difference. This is where spreadsheets come in.

    Peter Viechnicki, Strategic Analysis Manager and Data Scientist at Deloitte, adds that visualizing trends can help users avoid the most common data-related traps. 
  • Track big data
    Big data is trending across all industries. This means stakeholders expect a high-level view of what is working and what can be improved upon—complete with hard numbers and analytics. Privis Health explains that data collection will remain a focus in 2019, as value-based care is fueled by data.

  • Be sure to include these items in your dashboard.
    If you decide to create your CCM dashboard manually, you will need to incorporate the following items into your system:
  • Completed vs. ongoing patients
    When building your dashboard, you will need to measure how many patients you’ve completed in relation to how many patients you still need to work on. This is an essential data point.
  • Task tracking and time tracking
    Having a task tracker and a time tracker will create a natural checks and balances system for your healthcare organization. This will allow you and your team to monitor staff efficiency and accuracy—especially where electronic medical records are concerned.

    And, since Medicare will reimburse for eligible CCM time, the right kind of software will make it easy to track and implement follow-up tasks that are crucial to the patient experience, as well as the billing process and the efficiency of your practice.
  • Filtering
    A solid filtering system will allow your team to see which patients are close to reaching their CCM goals.
  • Billables
    At the end of the month, your dashboard should tell you which clients need to have their claims submitted. This is important because claims are how you get paid for providing CCM services.

Tracking CCM on your own can be challenging. Although there are pros and cons to both creating your own dashboard and opting for a software solution, the truth is that you can’t go wrong. Either option will benefit your practice and your patients.

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