Enrolling Patients in CCM

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 ManagementPrevisitLanding

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

CCM Create New 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.CCM Pt Search to Enroll

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.