Chronic Care Management in the Time of COVID-19

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Original story posted on: November 30, 2020

CCM appears to be positioned to be effective for improving patient care during the pandemic.

Previously, we’ve discussed the numerous benefits of incorporating chronic care management (CCM) into a primary care practice. CCM is intended to help care for the sickest and most challenging Medicare patients, those with two or more significant chronic conditions (which represents up to 80 percent of this population), along with enhancing the ability to regularly and proactively reach this subset of patients between office visits.

Supporting and motivating them to follow a individual plan of care makes them healthier and feel more satisfied. Given the fact that providers also could significantly increase Medicare reimbursement with minimal additional effort, this endeavor almost seems too good to be true! Perhaps this is the reason it continues to be so underutilized.

Here’s a key question, though. As beneficial as CCM can be during normal times, how effective would it be at improving the ability to care for patients during this prolonged pandemic? This goes for COVID-related issues as well as for other preventable and treatable conditions. 

The COVID-19 pandemic has highlighted the many weaknesses and shortcomings in our current healthcare system’s design and basic structure. Further, it has literally transformed the U.S. healthcare system in a relatively short period of time. And let’s be realistic; many of these changes will persist well after society gets back to any semblance of normal. Patients have learned to enjoy the convenience of remote visits, while providers have become familiar with the health benefits, as well as the ease of reimbursement for many of these services.

Even with several promising vaccines now emerging, the end does not seem to be clearly in sight. Cases continue to rise steeply everywhere, and with that trend comes persistent fear of contracting the illness, especially among the elderly, vulnerable, CCM-eligible population.

There is the obvious and ongoing need for wearing masks, social distancing, and self-quarantining. Patients continue to be hesitant to schedule in-office visits due to safety concerns, despite all reasonable safeguards being instituted. Many practices are not open at anywhere near full capacity. All of this greatly increases the challenge of maintaining “business as usual” for the average primary care practice. This has created a vacuum, as providers cannot rely on their traditional menu of services to be able to deliver great care for patients, nor to maintain financial viability. 

And while Medicare has expanded opportunities for reimbursement of telemedicine services in response to the pandemic, many providers have pondered retirement rather than learning how to deliver them.

So, then, how does a primary care practice deliver valuable and timely care for its patients, especially the most vulnerable among them, while also maintaining or even increasing reimbursement levels and provider satisfaction, all while avoiding the requirement to learn any new skills or take on any meaningful expense?

Enter CCM.

But how does a practice actually get started with CCM? After all, with a variety of compliance, operational, and financial matters to learn and consider, it can all still seem overwhelming. 

A practice can certainly start a program on its own, but in most cases and for most practices, especially now, the right answer is likely to partner with a professional group that already has both the expertise and systems in place to deliver a successful and rewarding CCM program, hassle-free – all with a firm understanding of the ever-evolving variety of compliance issues involved.

Some potential advantages to a professional CCM partnership, and things to look for when choosing a partner:

    1. A turnkey solution with no out-of-pocket expense;
    2. An extensively experienced, knowledgeable, and compliant team of experts;
    3. No additional staff required, and it can actually improve the efficiency of current staff;
    4. The ability for full assimilation with your current practice flow;
    5. A technology platform that integrates with the electronic medical record (EMR) for easy transfer of data and documentation to and from remote “health coaches;”
    6. The existence of several levels or methods of implementation;
    7. An emphasis on improved efficiency and value of office visits;
    8. The ability to maximize reimbursement for services provided under general supervision;
    9. The ability to incorporate other practical, rewarding, and related services with CCM, such as RPM, AWV, and ACP; and
    10. The ability to take the lead in the rare event of an audit.

These remote “health coaches,” working as representatives of the primary care practice, can help drive and enhance patient engagement, which is imperative during this COVID-19 pandemic and after. In addition to addressing concerns and methods to improve the management of chronic conditions, they can provide a variety of much-needed ancillary services, such as the use of and need for medical supplies, coordination of durable medical equipment (DME), and/or assistance with finding local services such as grocery and/or meal delivery.

For many CCM-eligible patients, this is a greatly appreciated service.

Andrew H. Dombro, MD

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