July 6, 2018 | Choosing the Right CCM Provider

Whether you’re looking for a replacement for CareSync, unhappy with your current provider, or dissatisfied with managing your chronic care services in-house – you’ll want to find a solution that encompasses the multifaceted requirements of CCM and a provider that can deliver on its promises.


Here’s what the right CCM provider should be able to speak to:

Patient-Centric Model

First and foremost – we must keep in mind the very reason for which the CCM program exists: to enhance patient health. Despite the financial benefits for all parties involved, patient health is of utmost importance. If we’re not adding value for them, we must rethink our position and realign ourselves to do well by the patient. For the program to be worth it, patient population health must be improving. Overall, we should see that patients are experiencing fewer visits to the ER and less time in nursing homes.

Preventative health measures are necessary and should be a routine part of CCM.

By speaking to a nurse on a regular basis, medical staff can preempt medical issues before or as they arise. This allows patients to address potential issues earlier, and receive treatment when necessary and before a condition worsens. As we know, it prevents more serious issues from arising, which may lead to the snowball of more medications, more time in hospitals, more infections and so on.

Patients also should be reviewed and advised on eligible pre-screenings. That information can be retrieved directly from Medicare on a regular basis. This way, physicians are aware and make recommendations for the patient for timely screenings such as mammograms, colonoscopies, eye exams or dental exams. CCM program models should also be individualized per each patient. There is no one-size-fits-all when it comes to medical care – so a CCM program should reflect that of course. This requires in-depth chart reviews per patient each month. A patient’s health is constantly fluctuating and maintaining a watchful eye on a consistent basis is important.

Patients should be able to set their own unique health goals and be educated and advised on what they need to do in order to get there.

For example, a nurse may suggest a patient maintain the blood pressure of 130/80 by eating a low sodium diet and limiting alcohol. The goals and education should be different for each patient, and dependent upon medical history gathered from an in-depth chart review.

Patients need to feel part of the process and patient education is a huge part of the process. Patients should feel empowered to understand their health and the ways in which they can make progress. We find it incredibly useful to take the time to provide the patient with individualized health education materials as well as explanations via phone call. When patients are part of the process. they appreciate the transparency and put more effort into their improvements. Putting the patient first is paramount.

Direct EMR Documentation – No disruption to workflow 

The biggest problem we’ve seen with many CCM providers is the technology aspect. Many CCM providers claim integration with physician workflow and tech platforms. However, this tends to require a considerable amount of time and resources surrounding the medical staff involved.

We believe that a CCM provider should document all medical information directly into the physician’s existing EMR just as in-office staff would. The medical staff should work as an extension of your office. However, EMR training should not be the responsibility of the practice. A Registered Nurse, already trained in the physician’s EMR, should be provided for this program. Otherwise, the time and resources that it takes to train is huge speedbump in getting CCM up and running for your patients.

With pre-trained, highly-qualified nursing staff, your practice can be up and running with CCM in less than a month. Training and implementations shouldn’t be a huge hurdle you have to cross.

Accurate Documentation

Many physicians prefer to use a Health Documentation Specialist (HDS) for consistency in their EMR. Your CCM provider should use an HDS team so that you can count on the accuracy in your EMR if you’re billing Medicare.

Quick Implementation

What else does it take to get CCM up and running? Implementing the program should be a smooth, previously-tested process. The first step is pulling patient data and checking for eligibility. This may take a considerable amount of time if done in-house. Any CCM provider should be prepared for this process. From a list of total patients – the CCM provider will then create of patients who are eligible for Medicare CCM.

Patient onboarding can take a significant amount of time and money as well. Providers should take a systematic, ethical approach here. Patients need to be thoroughly informed and provide verbal consent to the program. Documentation of this process is important.

Patient education is also important here so they should definitely receive information in writing. CCM providers should provide both the mailings and enrollment phone calls on your behalf. This should occur with an efficient and thoughtful approach.

High-Quality Clinical Staff 

Medical staff providing the CCM services should be highly trained and experienced. Ideally, the care should be provided by a Registered Nurse or higher certification. It’s also important that the staff are capable of warm “bedside manner” as much of the care provided is based on providing meaningful, thoughtful information to the patient. Many times, although the program is for chronic illness – it tends to fall hand in hand with mental/behavioral health – and therefore – the tone of care provided becomes important.

Consistency is also important. Patients enjoy developing a relationship with their care provider. Hearing a familiar voice helps patients share more about their health, and feel more comfortable with the process. Also, over time RNs may be able to develop a better understanding of their patient in order to provide even better care.

Namely, the key component here is a focus on the patient. The goal is to provide value to the patient by enhancing their health. A business model that prioritizes revenue or adaptation of new EMR-integration technology over patient health isn’t taking the right approach.

Here at Wellbox, we know we’re taking a better approach because we’re witnessing the results, firsthand. Wellbox patients are healthier and our physicians are experiencing the benefits – gaining back time and resources in the process. The feedback we’re getting has been overwhelmingly positive – with over 95% of patients describing themselves as “satisfied” with the program.

With CCM still in its’ earliest stages, the companies that go on to become leaders will take this opportunity to take stock and learn from its earlier mistakes. I think we can all agree that putting patient health first while allowing physicians to easily adopt the program is a great first step to achieving a healthier population!


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