Chronic Care Management (CCM) is a service offered within the primary care setting and provides patients living with chronic conditions additional help in managing their health. Unmanaged chronic conditions often lead to frequent expensive hospitalizations and premature deaths. CMS highlights that a staggering 117 million adults have one or more chronic health conditions with a quarter of those adults suffering from two or more chronic conditions. Finding interactive and comprehensive ways to help patients manage their chronic conditions will help reduce healthcare spending and allow patients to increase their quality of life. To qualify for CCM under Medicare guidelines, the patient must have 2 or more chronic conditions that are expected to last 12 months or longer and will significantly increase their risk of death or acute exacerbation. The healthcare provider will work with the patient to develop a detailed care plan that lists problems and goals, identify the patient’s healthcare team, medications, and community resources the patient would benefit from. The healthcare provider also ensures the patient has round the clock access to care for urgent medical concerns and support.
Accessing Chronic Care Management
Users will find the CCM link in the navigation menu on the left of the screen. This link will open a page that shows all of the patients in the portal in alphabetical order. The search bar at the top of the screen enables users to search for a patient by name, ICD-10, last medication time, and monthly time logged. If a search patient is not in the system, they will need to be imported from the EMR or created before enrolling them in CCM.
Enrolling a Patient and Creating a CCM Care Plan
To enroll a patient in CCM users will click the blue “Create New Plan” button in the upper right hand corner. In the resulting “Register New CCM Patient” window, users will search for the desired patient.
If the patient is not in the system, they may need to be either imported from a third party (EMR) or created in the system to move forward enrolling them in CCM. Once the appropriate patient in selected, click the blue “Next” button in the bottom right to create the patient’s care plan. In the resulting window, users will select the name of the patient’s provider and click “Next” to advance. To register a new CCM patients, users will need to input at least two chronic conditions that are being tracked through the program. Clicking inside of the text box, users will see a drop down of the most commonly tracked chronic conditions. Users can select conditions from this screen or free text conditions into the text box. The final window users will encounter before being able to create the patient’s care plan is a consent form.
Per CMS guidelines, patients need to consent to participating in the Medicare Chronic Care Management Program. The patients will need to understand CCM Program Benefits, how to revoke their participation in CCM, that their health information may be shared with their other medical providers, that only one practitioner can bill for CCM per month, and that there may be a copay for the service based on their insurance plan. Once the patient gives verbal and/or written consent, users will check the box stating that the patient has been fully educated on the program and gives their consent to participate. Users will then work through setting up the patient’s individualized care plan by following the prompts in the wizard. These prompts are displayed in a series of collapsible tabs. Users will need to go into each tab to verify, edit, or input information. If tabs are not completed or are missing information, the portal will flag the user and not advance until the problem is remedied.
Tracked Problem List: In this tab, users should list all major treated conditions or problems that are going to be tracked through the program. Prevounce will populate this information based on the conditions input at the beginning of creating a care plan and information collected during previous preventative services done for the patient using the portal. This text box is free text and users can edit, add, or remove information as needed.
Measurable Treatment Goals: In this tab, users will record goals for the patient. Prevounce will populate the conditions to be tracked as well as suggestions as to what the goals may be for that particular condition. Users are able to edit, add, or remove information listed in these goals by selecting the goal(s) that they want and clicking the “show editor” button in the bottom left. This will open a free text box where users can edit the information for any checked goals from the previous screen. To return to the Measurable Treatment Goals users should hit the “show wizard” button in the bottom left.
Barriers to Goals and Patient Concerns: In this tab, users will record the major barriers or concerns that the patient has about their own health. Similarly to the Measurable Treatment Goals tab, all of the suggested barriers and concerns can be edited, added to, or subtracted from by checking the barrier and clicking the “show editor” button in the bottom left.
Patient Instructions: In this tab, users will record instructions for the patient to assist with tracking each condition and streamlining the flow of information along the continuum of care. The suggested instructions can be edited by selecting the specific instruction(s) and clicking show editor in the bottom left as described above.
Medication Management: In this tab, users will record all of the medications that the patient is currently taking. This section will automatically populate with any information collected during a previous encounter within the Prevounce platform. Medications can be added by clicking the blue “Add Medication” button in the upper right, and existing medications can be edited or deleted by using the action button directly to the left of the medication name.
Community and Social Resources: In this tab, users will record any community resources that the patient may benefit from in their community. Prevounce populates suggestions based on the patient’s demographic information to large scale support systems; however, more localized and individualized support can be added per patient using the “show editor” button as previously described, or Prevounce can add in support systems that a practice would like available within the portal to all of their patients.
Provider Information: In this tab, users will list all of the patient’s current healthcare providers within the free text box provided.
Other Information: This tab is provided simply for the purpose of recording any critical information pertinent to the patient or their care plan that doesn’t fit into the categories above. This tab exists solely as a free text box that users can enter information into if needed. Completion of this tab is not necessary to advance.
Once all of the information has been entered, the user will click “Next” to advance. The following screen will show an overview the proposed care initial care plan. Users should review this information before submitting the care plan. If anything is incorrect or information needs to be added, users can click the blue “Back” button in the bottom right. If everything is correct and the user is ready to move forward, clicking the green “Submit” in the bottom left corner will finalize the care plan and advance the user to the patient’s unique CCM care plan page where all encounters will be logged.
This foundational care plan can be edited at any point in time by clicking the teal “Actions” button on the main CCM page to the right of the patient’s name and choosing “Edit Plan.