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.
Logging an Encounter
To log a CCM encounter, users must navigate to a patient’s care plan. If the user just finished enrolling a patient in the program, they will be automatically sent to the patients now-established care plan. If the patient was enrolled prior to this encounter, they can be found using the search functionality on the main CCM landing page. Once a user has located their patient, they can open the care plan by either using the teal “Actions” button to the right of the patient’s name and choosing “View Detail” or by double clicking on the patient’s name itself.
Inside of the care plan users will first see patient information displayed across the top of the screen. Just below the patient information, users will find a progress bar and a timer. While initially grey, the progress bar tracks the amount of time spent with a patient doing CCM per month. As time spent accumulates, the bar will slowly fill and turn blue. After a billable amount of time lapses, indicators above the progress bar that are initially grey with a minus sign turn green with a check mark. The timer can be used in two ways. Best practice is that the timer be used in real time. Once in the care plan, users should start the timer and choose an activity from the drop down to signify the Activity/Purpose of the encounter. Notes can also be added in this section for any pertinent information either describing the encounter or from the encounter that doesn’t fit in to the care plan. If a user forgets to start the timer, time can also be manually entered by clicking within the text box and entering the time spent.
Just below the timer users will find the patient’s care plan. This section of the page is separated into two columns and again into rows mimicking the tabs from the initial care plan creation. The left column displays the patient’s individual care plan. Each section can be edited individually if needed by clicking the teal “Edit” button in the upper right corner of the appropriate box. The right column is used for tracking interactions with the patient and will automatically show the last entry created for each section. For example, if during an encounter a specific tracked problem is discussed, it can be entered on the right by clicking the teal “Add Entry” button in the upper right of the corresponding box. This will track entries so that no matter which user is interacting with the patient next; they will have access to the notes from previous encounters. Users can also click the grey “View Recent Entries” button in the upper right to view a more extensive documentation of patient interactions.
After ending an encounter, it is critical that users return to the timer section, stop the timer, and click the teal “Log Time” button in the bottom left. Here users will also see a grey “View Time Log” section where they can view interaction history.
Finally, CMS requires that patients have access to their CCM care plan. Prevounce enables users to send the care plan to their patients via text or email, or download a pdf that can be printed and given to the patient or stored for the patient on a HIPAA compliant device. This can be done from either the patient’s care plan page, or the main CCM landing page. From the patient’s care plan, users should find the blue bar titled “Care Plan.”
All the way to the right of this bar is an “Actions” drop down from which users can choose to either “Send Plan” or “View Plan as PDF." Similarly, from the main CCM page, once the patient is located, users can use the teal “Actions” button to the right of the patient’s name and choose “Send Plan” which will give the user the option to send the information to the patient in either a text or an email.
To download the care plan as a pdf from the main CCM page, users will need to use the “Actions” button and choose “View Plan” which will take them to the patient’s CCM page where users can download the pdf as described above.