Our Flagship Program
Chronic Care Management (CPT code 99490) is mandatory for providers and health systems that accept Medicare patients.
We utilize clinically-proven chronic care management to improve care, reduce costs, and create financial stability. By engaging your patients, we can expand your reach and profitability beyond your exam room to capture "new" revenue while reducing risk
What Is Chronic Care Management?
The Centers for Medicare & Medicaid Services (CMS) recognizes care management as a critical component of primary care that contributes to better health and reduced spending.
Beginning January 1, 2015, Medicare pays separately under the Medicare Physician Fee Schedule (PFS) under American Medical Association Current Procedural Terminology (CPT) code 99490, for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple (2 or more) chronic conditions.
*CPT 99490 copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. For a summary on the Medicare Learning Network® (MLN), refer to the “Medicare Learning Network® Catalog of Products” located at
CCM Scope of Service Elements - Highlights
STRUCTURED DATA RECORDING
Record the patient’s demographics, problems, medications, and medication allergies and create structured clinical summary records using certified EHR technology
Create a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental
(re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues).
Provide the patient with a written or electronic copy of the care plan and document its provision in the medical record.
Ensure the care plan is available electronically at all times to anyone within the practice providing the CCM service.
Share the care plan electronically outside the practice as appropriate.
ACCESS TO CARE
Ensure 24-hour-a-day, 7-day-a-week (24/7) access to care management services, providing the patient with a means to make timely contact with health care practitioners in the practice who have access to the patient’s electronic care plan to address his or her urgent chronic care needs.
Ensure continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care. Do this through telephone, secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods, in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
Care management services such as:
Systematic assessment of the patient’s medical, functional, and psychosocial needs;
System-based approaches to ensure timely receipt of all recommended preventive care services;
Medication reconciliation with review of adherence and potential interactions; and
Oversight of patient self-management of medications.
Manage transitions between and among health care providers and settings, including referrals to other providers, including:
Providing follow-up after an emergency department visit, and after discharges from hospitals, skilled nursing facilities, or
other health care facilities.
Coordinate care with home and community based clinical service providers.
Additional Chronic Diseases
Cardiovascular Disease, Crohn's, Chronic Fatigue Syndrome, Chronic Pain, Chronic Renal Disease, Depression, Epilepsy, Fibromyalgia, Lupus, Mental Illness, Multiple Sclerosis, Obesity, Parkinson's, Sleep Apnea, etc.
Evidence-based chronic care model
About 48% of patients who are less engaged in their care suffer a health consequence due to poor care coordination and communication barriers, and 60% lose confidence in the healthcare system, making them less likely to comply with treatment plans.* Using an evidence-based, clinically researched chronic care model as developed by CCM and ICIC under ACA laws and guidelines, our SCORM compliant model helps by:
Facilitating the provider’s treatment instructions in a comprehensive care plan;
Promoting patient self-management through condition-specific education, helping them create attainable goals, and cultivating a health-conscious culture of learning;
Addressing communication barriers between care providers and patients utilizing specific behavioral, clinical, and educational principles to encourage positive change.
*Source: from AARP & You, “Beyond 50.09”
Chronic Care Program Highlights
Implement and monitor - and revise as needed - provider-guided care plan using clinical, behavorial, and educational measures.
By identifying barriers, we develop positive health outcomes by addressing healthcare behaviors in both patients and provider.
Address communication barriers between care providers and patients utilizing specific behavioral, clinical, and educational principles to encourage change.
Medication reconciliation with review of adherence and any interactions; and
oversight of patient self-management of medications.
Anytime access will support patient’s around the clock - with full EMR including documentation of their progress.
Our Engagement Measures
4-level engagement measure
Using a series of progressive assessment measures, activities, and surveys, our care team will determine each patients level of engagement with their healthcare and determine a course of training. The 4 levels include:
Disengaged. Individuals are passive and lack confidence. Health knowledge is low. Goal orientation is weak. Adherence is poor. Their perspective: “My doctor is in charge of my health.”
Becoming aware, but still struggling. Individuals have some knowledge, but large gaps remain. They believe health is largely out of their control, but can set simple goals. Their perspective: “I could be doing more.”
Taking Action. Individuals have the key facts and are building self-management skills. They strive for best practice behaviors, and are goal-oriented. Their perspective: “I’m part of my health care team.
Maintaining behaviors and pushing further. Individuals have adopted new behaviors, but may struggle in times of stress or change. Maintaining a healthy lifestyle is a key focus. Their perspective: “I’m my own advocate.”
Our Care team is educated on chronic conditions, as defined by NCQA measures, through a comprehensive training program and continual education.
Clinicians undergo advanced communication skills training to develop relationship skills for better interaction with patients and providers.
Compliant under all ACA measures, Medicare, and HIPAA through patient portals and EHR integration.
Our Core Features
Award-winning platform, gold-standard apps, EHR integration.
Expand your care team to reach patients beyond your daily schedule.
Care centers are staffed for your patients, under your orders; supervision.
Fits ACA measures, HIPAA compliant portals, EHR integration.
Annual Revenue Projection
You Can't Do This With Your EHR
By using predictive analytics and an enterprise solution, we will identify and stratify patients with the highest clinical and financial risks. By combining risk scores with other data, our Care Coaches will trigger Personalized Preventative Plan Services (PPPS) and other necessary treatments and/or testing procedures in a systematic way to support regular Doctor office visits. By managing each patients personalized care plan and prioritizing interventions -- all within a single workspace -- Doctors gain a 360 degree view of each patient, guiding better decisions at the point of care.
Making important business decisions demands accurate intelligence. Your comprehensive financial analysis - based on your service area - will provide the knowledge you need to forecast your population effectively.
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