Chronic Care Management (CCM)

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Our team has reviewed and analyzed hundreds of clinical, regulatory, financial and other materials related to the new ACA “Care Management” (CM) area of healthcare delivery. This research and review process, in concert with our team’s extensive healthcare experience, provides a strong foundation to build a customized CCM program for your health system or medical group.

It is important to note (our opinion) that we believe that Medicare created the 25 (approximate) different CCM services CPT codes to work together as a single clinical toolset, vs. offering some and not all of the services.  We can show you how implementation of this idea will create a stronger clinical model, with significant financial rewards as well.  Some of the clinical concepts and tools that we use are discussed below: 

CCM Clinical "Patient Assessment Tools:

Physicians perform “Medical Decision Making” (MDM) based on clinical information presented by a patient or gathered during a medical office visit encounter. Enhanced clinical information gathering is now required to successfully implement the new Medicare “Value Based Care” (VBC) programs and initiatives. We have approximately 50 different Objective clinical assessment (HRA) questionnaires that we can discuss with you to determine which ones will help your group succeed.

When these CCM questionnaires are completed, they create “Clinical Activities” for separate and distinct preventative services to be performed on a calendar basis as established by Medicare. The key concept here is automation of clinical workflows, sometimes referred to as “Clinical Decision Support” or CDS.  Automating these clinical tasks in accordance with Medicare and other clinically validated sources will help you achieve higher levels of success and enhanced patient engagement.

The Extended Care Team:

Healthcare delivery models, in their current design, do not provide enough time for a physician to consider the Whole Person that presents during a routine office visit/encounter. The physician needs to consider the patient’s presenting acute condition, any current chronic conditions and lastly, the required preventative services needs in accordance with clinical guidelines. Future models (which we embrace) of healthcare delivery include a robust “Extended Care/Clinical Team” to provide the appropriate level of care for the patient’s needs. The Extended Care Team model has been clinically researched and validated by Dr. Thomas Bodenheimer of UCSF. 

Clinical Activities:

It is important to note that your CCM "Allied Health" team members will operate under the General Supervision (a defined Medicare Term) of the enrolled patient’s Primary Care Physician Provider. Based on this requirement, trained (although non-licensed) team members are not authorized to perform MDM for the patients that we consult with. Regardless, multiple clinical activities can be identified through a comprehensive assessment process.  We use Clinical Mapping to create clinically validated (using clinical research and guidelines) clinical activities that have been authorized by the physician to recommend when we establish your new CCM program. The automation, regulatory research and clinical workflows that occur during this process will be completed customized for your Providers and their expectations.

Of course, there is alot more information needed to build a successful CCM program, call us to discuss the above ideas and much more.