Chronic care management (CCM) is a continuous care coordination for a patient who has a chronic health condition, such as a patient who requires regular monitoring, medication management, care planning, and communication between providers. CCM is covered by Medicare for eligible beneficiaries who have two or more qualifying chronic conditions that will likely last a minimum of 12 months or until the person’s death.
The best chronic care management software assists healthcare companies to manage ongoing care, arrange patient data, document clinical activity, and connect care teams between visits. It offers a layer of technology to enable the people, processes, and documentation needed for the effective care of chronic disease.
What Is Chronic Care Management Software?
Chronic care management software is an electronic tool that allows health care providers to provide more vigorous treatment to their chronic care patients. Care teams have the option of using one system to coordinate recurring activities and organize patient information, rather than relying on spreadsheets, disconnected notes, phone logs, and manual reminders.
Any platform really ought to be able to assist with clinical workflows and operational workflows. This covers patient enrollment, management of care plans, communication, tracking of tasks, documentation, alerts, reporting, and integration with the practice’s current electronic health record (EHR).
This is particularly important when patients increase. This workflow is manageable for 25 CCM patients but can be challenging for a practice with 200 or more patients needing to be sent regular outreach and documented.
Key Features to Look for in Chronic Care Management Software
Not all CCM platforms provide the same features. Healthcare organizations should determine if the software can be used for the entire care-management cycle, as opposed to just a patient database.
Comprehensive Care Plan Management
Care plans are at the heart of successful management of chronic diseases. According to CMS guidance, comprehensive care plans consist of components like problems, treatment goals, expected outcomes, interventions, symptom management, medication management, and coordination with other providers.
Authorized members of the care team should be able to easily create, update, review and document these plans with useful software. It should also be able to provide information that is relevant to patients as they engage with various members of their health care team.
EHR Integration
The integration of EHRs can help make or break a CCM program from being part of routine clinical care or becoming an additional administrative burden. To prevent duplicate data entry and enable clinicians to utilize a more comprehensive patient record, software that can communicate with current systems can be utilized.
Seek out platforms that integrate with current processes, rather than making workers constantly switch between unrelated applications. Evaluation of integration should happen during the purchasing process, as well as the transfer of patient demographics, clinical data, documentation, and pertinent care-management information between systems.
Patient Engagement & Outreach
Effective communication is a key ingredient to CCM. Medication reminders, education, discussion of symptoms, appointment coordination, or help coordinating the use of other health care services may be required.
These are examples of useful engagement skills:
- Automated and personalized communication.
- Two-way communication
- Remind users to attend an appointment or perform a task.
- Patient education
- Escalation workflows
- Record of attempts to outreach and interactions made
The best security systems are ones that are a combination of technology and human effort. Automation should help to eliminate repetitive administrative tasks and leave room for the caring team to make clinical decisions when necessary.
Documentation and Workflow Tracking
CCM is a series of activities that must be accurately documented and carried out repeatedly. With software, teams can monitor patient management activities such as outreach, interventions, care plan updates, clinical communications, and more.
CMS provides detailed requirements and billing instructions for CCM services, including time requirements for covered services. For instance, CMS has established the CPT 99490 for the first 20 minutes of clinical staff CCM time and CPT 99439 for each additional 20 minutes of CCM time as required under the applicable requirements.
Organizations should therefore look to software that will make the documentation process easier but not incentivize staff to document activity for the sake of billable minutes. The purpose is to provide appropriate and effective care with proper documentation.
The Advantages of Chronic Care Management Software in Enhancing Care Delivery
The most significant advantage of the CCM technology is not just another dashboard. It is helping to establish a more consistent methodology to assessing patient needs and responding to them before problems get worse.
Better Care Coordination
Those with a chronic condition may see various primary care providers, specialists, pharmacists, lab providers, hospital providers, and other health care providers. If not coordinated properly, data could be spread throughout organizations and systems.
A centralized CCM workflow makes it easier for care teams to see who has what responsibility, what’s not been done, what needs to be done, and what follow-up activities are there. CMS singles out coordination with outside practitioners and resources as an important element of comprehensive chronic care management.
Improved follow-up of patients. More regular follow-up of patients.
However, this does not always mean that the lack of clinical knowledge is the cause of missed follow-ups. These can arise due to working staff to capacity, the spreading of tasks among staff, poor documentation, or patients being hard to reach.
A structured software workflow can also assign tasks, highlight overdue tasks, and give visibility on who needs to be attended to. This provides consistency of operation that would be hard to sustain if the care coordination were mainly left to the memory of individual staff members.
Greater Operational Efficiency
Administrative tasks can be extensive for CCM programs, particularly if a program grows in size. Software can streamline repetitive tasks, eliminate redundant documentation and assist members of staff focus on tasks in need of human intervention.
A practical lesson for healthcare leaders is to take the measure of work avoided, not work completed. When those little savings add up, for a care coordinator, they can add up to five minutes over, say a few hundred patients and a few months, it can be significant.
Selecting the Proper CCM Platform for Your Practice
The optimal approach will vary by the patient population, staffing structure, EHR environment, and growth plans of an organization. For a small, independent primary care practice, simplicity and quick implementation is the most important goal, whereas for a health system, it involves deeper integration, analytics, scalability and multi-site administration.
The security, privacy and access of healthcare organizations should also be considered when selecting a vendor, as well as the reliability of the vendor.
Why are CCM and RPM increasingly linked?
Chronic care management and remote patient monitoring are two distinct aspects of the patient care journey, but can work together. RPM can deliver health data from the patient’s home, and CCM can offer continuous coordination, education, communication and care planning.
This larger framework becomes increasingly relevant as CMS looks for technology-driven strategies to chronic disease management.
The Benefits of Tellihealth as a Good Solution for CCM
But Tellihealth is a more comprehensive solution for organizations interested in using technology to complement human-centered chronic care. Its signalCCM solution integrates technology, coordination of care, patient engagement, EHR integration and support from care teams.
Tellihealth also integrates CCM with remote care functionality so that healthcare organizations can create more remote-friendly CCM programs for patients who require assistance beyond the walls of traditional clinics. The platform is engineered to streamline documentation, embed into workflows, and enable proactive patient communication.
Conclusion
Chronic care management software can help to streamline and automate the fragmented process of care coordination to create a structured, measurable process. The unique aspects of Tellihealth are its ability to integrate technology with human-centric CCM services, making it a robust solution that extends proactive chronic care while minimizing complexity.
FAQs
Who is the CCM technology suitable for?
CCM technology can be useful to primary care practices, specialty practices, hospitals, health systems, and large groups of patients with chronic diseases. This can be particularly helpful when there is frequent patient interaction between multiple providers and settings.
Will CCM software be a substitute for an EHR?
No, they are used to complement an EHR, not replace it. By integrating chronic care workflow into the current clinical environment and eliminating duplicate administrative tasks, care teams can realize chronic care management.
Is there CCM software that will support Medicare billing workflows?
It can facilitate documentation and workflows related to CCM but software is not a guarantee of billing eligibility nor of reimbursement. Practices are required to adhere to the applicable CMS rules, coding rules, patient eligibility requirements and documentation requirements.
