New and Improved CCM Services

New and Improved CCM Services

For three years, we have been providing Chronic Care Management Services and compiling patient and practice feedback in order to continuously improve our offering.

This being said, in an effort to enhance our program, we are now including other valid non-face-to-face care services. Our clinical team will be alternating between telephonic and purposeful postal mailing.

To help provide the best care to your patients, we want to clarify our workflow and break it up into Modules that follow a consistent pattern. In doing so, physicians will have simplified notes and better insight into how and when we will contact their patients. More focused modules will mean more focused notes:

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Mail Modules

  • First Care Plan Creation
  • Medication Analysis
  • Additional Care Plan Creation
  • Preventive Health Analysis

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Call Modules

  • Initial Care Plan Review
  • Medication Review
  • Subsequent Care Plan Review
  • Symptoms Management
  • Preventive Health Review

Please refer to the bottom of this page for details on each Module

We will also be adding social services and care coordination modules in 2018. These new Modules were developed with patient care and physician workflow in mind. We want to ensure we are a valuable extension to your practice and the care you provide.

Rest assured, this work falls within CMS guidelines for ongoing oversight, direction, and management in regards to CCM services

The first month will always be Module 1, with subsequent months depending on patient availability and health situations.

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Mail

Module 1: First Care Plan Creation
We will create a goal-oriented plan for the patient by analyzing their health record in detail. This plan will be mailed to the patient for them to review and then discuss with their nurse. It will also be shared with the physician to obtain their feedback.

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Call

Module 2: Initial Care Plan Review
This call focuses on educating the patient and aligning them with their plan. At this time, we will also identify barriers and ensure the patient has the resources to achieve their goals.

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Mail

Module 3: Medication Analysis
This will be an in-depth analysis of the patient’s medications. The patient’s nurse will send them educational material on high-risk medications and information on prescription assistance. The purpose of this is to set up a call with the patient for the following month to successfully review their medications, increase their compliance and understanding of medication, and help them to enroll in Rx assistance programs.

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Call

Module 4: Medication Review
This call will be a thorough review of the medications listed in the patient’s chart. The RN will ensure the patient’s record includes all medications and supplements. Patients will be educated on medications and the nurse will address compliance and adherence. Prescription assistance will also be addressed at this time.

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Mail

Module 5: Additional Care Plan Creation
Many patients have several Chronic Conditions, therefore further Care Plans will be developed and sent to the patient and physician. We will be using the Plans in place from their physician and ensuring patients have clear goals.

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Call

Module 6: Subsequent Care Plan Review
The nurse will call the patient to discuss the new Care Plan and discuss existing Care Plans.

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Call

Module 7: Symptoms Management
Using a list of questions created by our MDs that are specific to the patient’s conditions, we will be better equipped to help detect symptoms to communicate to the physician in a clear and concise way. This will ensure that the practice knows what symptoms the patient has and decide whether or not to bring them into the office per their policy.

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Mail

Module 8: Preventive Health Analysis
At this time, we will review the patient’s chart to see what Medicare preventative and screening services the patient has utilized. With this information, we will send them a worksheet to help them know what to discuss with their physician and prepare them for their Annual Wellness Visit.

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Call

Module 9: Preventive Health Review
This call will be to discuss what services are available to the patient and how they can obtain them. We will ensure the patient uses their worksheet to bring to their physician so they can track these important events and increase their quality measures.