Chronic Care Management Best Practices

There are several things that are imperative to creating a successful CCM program. 

1. Build a solid foundation with your providers. A strong and trusting relationship with clear communication is critical.  They need to understand CCM well enough to be able to refer a Medicare patient to you but leave the explanation of the program to the care coordinator.  Get their cell numbers and their permission to text them important patient information to create a seamless care coordination process for the patient.
2. Scan the schedules and pick out patients that qualify for CCM, let the provider know you would like to meet with the patient during the visit, let the patient know that their provider recommends the program, and if appropriate obtain consent to enroll them in CCM. Then send a referral to the provider stating that the patient would like to enroll in CCM so the provider can sign off so there is an audit trail.
3. Find ways to build spend time on the patient’s care such as education; create informational packets for things like Diabetes, COPD, and etc.. Make sure all their prescriptions get refilled at the same time, remind them of upcoming appointments with providers and specialists, review charts so you are as informed as possible, and so many other ways that you can be of help to them.  If it’s done on behalf of a patient the time can count.
4. Be available for the patient and follow through. If you tell them you are going to do something for them make sure it gets done.  Lack of follow through will destroy your patient’s trust in you and the CCM program.

Hat tip to Margo Flores of Cobre Valley Regional Medical Center in Globe, Arizona