CCM Quick Start Guide

  1. Users will find the CCM link in the navigation menu on the left side of the screen.
  2. This link will open a page that displays all patients in the portal in alphabetical order
    1. Search bar at the top of the screen can be used to search by patient name, ICD-10, last modification time, and monthly time logged.
    2. If users search for a patient and they do not show up in the system, the patient will need to be either imported from a third party (EMR) or created before they can be enrolled in CCM.
  3. Importing a Patient:
    1. Users will click “Import from Third Party” which will prompt the user to log into their EMR.
    2. Users will again search for the patient.
      1. Once the patient is found and verified, users will click the blue “Import” button to the right of the patient’s name.
      2. Once the import is complete, users will be able to search and find the patient in the “Register New CCM Patient” screen and follow the steps below to enroll.
  4. Enrolling a New Patient:
    1. Users will click the blue “Create New Plan” button in the upper right of the main CCM landing page.
    2. In the resulting window, users will search for and select the desired patient before clicking the blue “Next” button.
    3. Users will select the billing provider and the “Next.”
    4. To register a patient in CCM, users will need to input at least two chronic conditions.
    5. CMS requires that patients consent to being in the CCM program and this should be documented within the portal.
    6. Users will set up a patient’s individual care plan by following the prompts and working through the tabbed Care Plan Wizard.
  5. Logging a CCM Encounter with an Enrolled Patient:
    1. To log a CCM encounter, users must navigate to that patient’s care plan.
      1. Once the patient is located, users can access the care plan by double clicking on the patient’s name or using the teal “Actions” button to “View Detail.”
    2. Once in the care plan, users should start the built in timer and choose an activity type from the drop down tab.
      1. Time can be entered manually if a user forgets to start the timer
      2. The progress bar will turn blue as time accumulates. Check marks will turn green to indicate a billable amount of time has been reached.
    3. Notes for the encounter can be listed in the “Notes” section.
    4. Edits to the care plan can be made in the section marked “Care Plan”
      1. The left column displays the patient’s individual care plan. Each section can be edited independently by clicking the teal “Edit” button
      2. The right column is used for tracking interactions and will automatically show the last entry created for each section
    5. To end an encounter, users must return to the timer section, stop the timer, and click the teal “Log Time” button in the bottom left.
    6. Note: CMS requires patients have access to their care plan. Users can choose to either send a link to the care plan to patients via text or email or the plan can be downloaded and printed. Users can access these features by choosing “Send Plan” or “View Plan as PDF” from the “Action” buttons located either within the patient’s care plan or from the main CCM page next to the patient’s name.
  6. Un-enrolling a Patient:
    1. Patients can be unenrolled from either the main CCM page or their individual patient page. Users can do this in either location by navigating to the “Actions” button and choosing the “Un-Enroll Patient” option.