Build a strong patient communication strategy.
Enlisting patients in the CCM program takes some strategic communication planning and effort. For us, it was more effective to sit down discuss the program with patients when they were in our clinic rather than calling them or sending a letter after their visit.
We found the best way to increase patient enrollment was by explaining the value of the program. We told patients that through this program they would have 24/7 access to certified clinicians. These clinicians would help them manage chronic conditions and notify the full care team in case any treatment plans needed to be updated. Some other value points to discuss include:
- careful and close coordination among providers and specialists;
- personal attention to patients’ health needs to prevent hospitalization;
- support in the arrangement of needed services, such as transportation; and
- assistance in booking appointments and managing medications.
That makes attrition, having patients opt out of CCM, a nonissue for us. Once patients experience the high-touch care coordination, they see the benefit of sticking with it over time.
Deliver success in multiple ways
Establishing a CCM program allows us to be successful in this value-based healthcare environment. As MACRA and other value-based payment models evolve, it is imperative that independent primary care providers work to better manage the cost and care of chronically ill patients.
Because our chronic care team stays in contact with patients’ physicians, we have access to complete patient information and test results from other providers, helping us save money by not ordering unnecessary or duplicative tests.
It’s become clear to us that CCM is the way medicine should be delivered. Participating patients recognize the value of the additional service and its role in improving their health outcomes. Because of our CCM program, we’ve seen better care quality and coordination of our complex patients with fewer pitfalls. For example:
- Within the first few months of launching our CCM program, we were able to secure more than 30 disabled parking stickers for patients who were entitled to them but needed help navigating through the complex process.
- A patient with a challenging lung condition sought treatment with an out-of-state specialty hospital. During his treatment, our care coordinators worked with the hospital and laboratory to collect his test results, monitor his specialty medications, communicate with our team, and ask questions about how to optimize follow-up care at our clinic. Having all the patient information in one place and collaborating care with the out-of-state providers ultimately improved the patient’s adherence to his treatment plan, which resulted in a better health outcome.
- Another patient recently commented our office is more efficient than we used to be. We directly attribute that to the follow-up care coordination from our CCM efforts.
Best of all, participating patients think the program is fantastic, and they truly see the value. That itself makes the CCM program worth it to us. It may be worthwhile for other independent practices looking for new sources of reimbursement and ways to improve care management among patients with chronic conditions to consider adopting a CCM program, too.
Nicolas Chronos, MD, FACC, FESC, is the medical director of Cardiology Care Clinic in Eatonton, Ga. Chronos is an interventional cardiologist. His cardiology practice focuses on general cardiology, coronary artery disease management, and heart failure management.