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Chronic Care Management Software Guide
The Chronic Care Management Program (CCM) was initiated by Medicare for patients with two more chronic conditions to help manage their care. The main goal of the program is to find the gaps, improve the quality of life, prevent complications, and reduce healthcare costs. Providers need to have a robust Chronic Care Management software solution that will help manage the participants as per the guidelines set by CMS. Learn more about EHR and its role in healthcare on HealthIT.gov.
The objective of the Chronic Care Management Program is to provide non-face to face services for patients with two or more chronic conditions suspected to last at least 12 months, or until the death of the patient. The requirements and program guidelines are important to manage and submit each CCM encounter. Choosing the right platform that is compliant is paramount to the success of the program.
What are the features and requirements of the Chronic Care Management software platform?
At a minimum, the software should have the following features and functionalities to comply with the CMS guidelines.
Patient consent and management – The software should have features to record patient consent which is mandatory before starting the Chronic Care Management Program. This will help the practice to understand the number of patients who consented and were interested in the program.
Chronic conditions - The Chronic Care Management software should be able to help document and track chronic conditions such COPD, diabetes, hypertension, depression, or heart disease. It should also provide templates and customization to document other chronic diseases.
Charting and documentation – Allow clinical staff to document patients’ specific questions, chart the responses, and accurately generate comprehensive documentation in strict compliance with CMS guidelines.
Comprehensive care plans – Include care plans that can be further customized based on the practice or patient requirements. This will help the clinic to monitor the patient’s progress each month with precision and accuracy. The software should have the flexibility to create, update, and maintain personalized care plans for patients with chronic conditions. The care plan should have medical history, medications, goals of care, follow-up schedules, interventions and expected outcomes.
Tracking and documentation – Track and time interactions and time spent beyond the call. This is especially important for practices to establish the validity of calls and help submitting claims. The software should track the time spent on Chronic Care Management activities and ensure it meets the minimum 20 minutes of compliance requirements.
Patient communication and engagement – HIPAA Compliant communication for secure messaging, phone calls, and emails between the patients, care givers, and the providers.
Patient Portal – Provide easy to use patient portal access where patients can view their care plans, communicate securely with care teams, and access any educational resources as provided/needed.
Patients Engagement and Monitoring – Provide patient engagement tools and technology that will improve the patient’s engagement, collaboration, and proactive management during the CCM engagement.
Billing features – The ability to generate superbills and bill for the CPT codes as per the program requirements. The software should be able to generate automated or semi-automated billing code generations for the CPT codes like 99490, 99439, and 99487 to ensure timely and proper claims generation and billing.
Audit requirements – Important audit proof documentations, comprehensive digital care plans, and easy access to patient’s health plans in a central location document are necessary.
Remote Patient Monitoring – It is beneficial to integrate Remote Patient Monitoring devices for real time data on vital signs and other health metrics.
Ability to scale add patients – Built in flexibility to accommodate the above-mentioned features and easily scale as per the practice requirements and demand.
How to streamline the Chronic Care Management Program for your practice?
Assess organizational readiness in terms of bandwidth, staff training, and technology infrastructure.
Select the Chronic Care Management Software that meets the compliance and functionality requirements.
Integrated with EMR and RPM – The CCM should be able to integrate with your EMR and RPM devices to provide centralized access to information that will help providers make well informed decisions.
CCM software should provide complete process flow and workflow to ensure compliance with CMS guidelines.
Features should be easy to navigate and the staff properly trained to ensure compliance with CMS guidelines.
Metrics should be available to monitor performance and suggest improvements for the practice to adapt.
How can the Enable Healthcare Chronic Care Management platform help your practice?
Patient engagement and compliance: Increase patient engagement and compliance through well designed technology, process, and workflow, including a patient portal. This technology helps establish automated communications and alerts the staff.
Improve communication: Our platform helps the practice bridge the gap of communication leading to better compliance, participation, and a passive revenue stream.
Transparency and reports: Complete transparency with the patient engagement, compliance, participation, and real time dashboards and reports.
Increased revenue: increases revenue through proper engagement, patient satisfaction, and compliance.
Turnkey platform: With care plans, patient engagement tools, billing, audit, and time tracking mechanisms as per CMS guidelines.
Training and support: To ensure practices are well equipped to run the program in-house, using the CCM software.
How can EHI help with the Chronic Care Management program?
1). Identify the patients: Our software helps identify patients with two or more chronic conditions. In addition, our software will also identify eligible populations based on the last visit date and payer participation.
2). Enrollment: Our technology platform will easily enroll patients and create a personal CCM patient chart in seconds.
3). Review care plans: Create care plans from the existing templates or customize one based on your patient’s needs.
4). Monthly nurse calls: Use your clinical staff or outsource to the EHI nursing team to make phone calls to the eligible populations.
5). Track time and document information, then create and bill for the appropriate CPT code(s).
Why choose Enable Healthcare for Chronic Care Management?
1). EHI has been providing these services since 2016. It has multi-lingual clinical staff, technology, and processes in place to work with small, medium, and large practitioners, FQHCs, and RHCs.
2). EHI offers a complete turnkey solution. From patient enrollment, onboarding, to monthly nurse calls and follow up, then billing- EHI does it all for you. Our care coordination team follows up diligently with the eligible population and informs and update practices using the CCM application.
3). Practices that have dedicated clinical staff can leverage our CCM software as a service. Our advanced technology platform is CMS compliant and enables us to offer audit proof documentation, comprehensive care plans, and easy to access health information all in one place. With our platform, patients can stay informed about their health status, upcoming appointments, medications schedules, and communicate with healthcare professionals anytime, from anywhere.
4). Our clinical staff engage patients monthly and establish a connection with them. They discuss diverse topics such as transition of care, chronic care plans, and social services such as meals on wheels and transportation barriers.
5). We at EHI believe strong practice collaboration, practice education, and practice endorsement of these programs to their patient populations help improve overall patient participation and compliance.
Ready to streamline your Chronic Care Management program with the best software solution available? Contact Enable Healthcare today to learn more about how our CCM platform can help improve patient engagement, increase compliance, and enhance your practice’s efficiency. Contact Enable Healthcare.
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