Nearly 117 million Americans have more than one chronic health condition, according to the Centers for Medicare and Medicaid Service (CMS). By 2025, chronic diseases are expected to affect nearly 164 Americans. That’s almost half of the U.S. population.

It’s more important than ever before — and will be increasingly important — to find effective ways to help patients manage their chronic diseases. The trick in the age of value-based care is for independent practices to do so in ways that also contribute positively to their bottom line.

One way is to build a strong program that tackles the most prevalent conditions within the local patient population and make use of CMS’s chronic care management (CCM) service codes. These codes recognize CCM as a “critical component of primary care that contributes to better health and care” for patients. Practices can be reimbursed for time spent developing and administering a comprehensive care plan for patients with two or more chronic conditions that place them at greater risk for death. That may include cardiovascular disease, diabetes, and asthma, among others.

Implementing a CCM program has improved our ability to help patients better manage their chronic conditions and provide more coordinated care overall, especially for some of our sickest patients.

Fortunately, with careful planning and a third-party partner that understands patient care, we were able to integrate care coordinators into our practice without adding extra work for our already busy clinical and administrative teams.

Here are three best practices we followed to create a comprehensive CCM program for our independent practice.

Make CCM an integral part of your practice.

The last thing we wanted to do was to treat CCM as a separate program from the rest of the practice.  Since we are using a care management service provider, we thought it was important to embed experienced care coordinators into our practice. That means having them use the same equipment and technology as the internal clinical and administrative teams and including them as vital members of the care team.

We assigned CCM staff the responsibility of gathering results and coordinating among providers, then documenting and sharing that information with the practice and patients as appropriate. We have found the best way for our practice to get the total value of Medicare contributed dollars is to ensure that the data gathered through CCM is fully utilized.

Because CCM is such an integral part of our practice, we have developed a close relationship with our CCM provider. That relationship has helped us establish an effective program, which we have adapted to meet our practice’s individual needs and goals. That tight integration is also key for ensuring everyone understands and properly documents the services provided. As a result, our billing is more accurate. We have fewer denied claims and a higher reimbursement rate than when we tried to do it ourselves.  

 

Involve a key clinical team member.

Ask a lead physician or a senior nurse practitioner to advocate for the program, actively move it forward from patient enrollment to EHR integration, and help solve challenges as they arise. That will also reduce or avoid service delays for patients. Delays can be caused by a number of reasons, including if care coordinators are hindered by lack of access to the internet or other tools, if care coordinators are having trouble synching records with another organization to get test results in a timely manner, or if patients need more information to help them sign up for the program or follow their treatment plans.