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The way medicine should be practiced


One independent practice has improved patient outcomes, employee efficiency, and practice revenue by implementing a chronic care management program.

care coordination, chronic care management, CCM, diabetes, Triple Aim, asthma

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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. 

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.

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