Chronic Care Management

Chronic Care Management (CCM) is care coordination that is outside of the physicians office and is non-face-to-face services provided to patients that have at least 2 (two) chronic conditions.

Overview

The ChronWell CCM program includes the development of a physician approved care plan with monthly communication to patients and other treating health professionals for patients with 2 or more chronic conditions. The Chronic Care Manager (MD, PA, NP) will work with patients remotely and will include:

  • Care coordination between the practice and patient
  • Referral management 
  • Medication management
  • Care plan adherence

The designated Care Manager establishes, implements, revises, monitors and manages an electronic care plan that addresses the physical, mental, cognitive, psychosocial, functional, and environmental needs of the patient as well as maintains an inventory of resources and support that the patient needs. Chronic care management is an extension of the care delivered by the clinician at the point of care and provides 24/7 access to a clinician. The patient will receive the care plan and updates monthly. 

Overview

How We Measure Program Success

Graphic

Financial

  • Maximizing patient enrollment
    • Office enrollment
    • Telephonic enrollment
  • Meeting set financial goals for the practice
  • Increasing appropriate office visit opportunities
Graphic

Medical

  • Medication and medical adherence tracking
  • Coordination of care and referal management 
  • Ongoing review of medical status and risk
  • Lifestyle changes and healthy habit development
Graphic

Patient Engagement

  • A minimum of 20 minutes of monthly clinical staff time 
  • Provide education to the patient, family and caretakers
  • Serving as the liaison between the patient and the practice
  • Stress and anxiety coaching 
  • Assistance with Remote Patient Monitoring (RPM)
Graphic

Other

  • Patient satisfaction
  • Cost to provider of acquiring patients
  • Revenues generated to provider

To learn more about Chronic Care Management, schedule a call with ChronWell today.

right shape green