CCM software helps healthcare providers manage chronic conditions and organize patient information. The right platform enables care teams to establish a streamlined workflow for repetitive activities and keeps providers updated on patients with complex or multiple chronic conditions.
Software for chronic care management is a continuous way of providing care coordination, comprehensive care planning, medication management, communication, and access to care to eligible patients who have chronic conditions. For people who have two or more chronic conditions that are likely to last a year or longer, or until the patient’s death (as long as the requirements are met), Medicare considers the CCM to be “extensive, intensive, or comprehensive.”
Key Features to Look for in CCM Software
Comprehensive Care Plan Management
An updated care plan is an essential component of coordinated chronic care. Care plans should be created, reviewed, updated, and documented on the platform as patient needs evolve, and the platform should enable authorized members of the team to do so.
Useful capabilities include:
- Personalized goals and interventions
- Medication information
- Tracking of problems and conditions.
- Care-plan updates
- Specialist and provider coordination
- Patient preferences documented
- Monitoring and management activities for follow-up and care milestones
A care plan should be a working clinical document, not a document in a patient’s record.
EHR Integration
One of the most crucial technical factors to take into account when choosing a CCM platform is EHR integration. But if there is a lot of duplication of information being transferred back and forth between systems, it can create more work for staff than it saves.
Patient Engagement Tools
Continuous patient communication is the main key of CCM. Outreach should not be the same monotonous message sent to everyone, but should be easier for care teams to stay in regular contact with.
Be on the lookout for features like:
- Phone-based outreach workflows
- Secure messaging
- Automated reminders
- Appointment reminders
- Medication-related support
- Two-way communication
- Escalation of patient concerns
- Personalized education
The repetitive administrative tasks should be automated, and the remaining administrative and complex communication responsibilities delegated to people with the proper training.
How CCM Software Supports Better Care Coordination
People with multiple chronic health conditions tend to have multiple providers and entities involved in their care. If there is no workflow in place, vital information can be lost, follow-up instructions can be overlooked, and patients may receive different instructions.
A centralized system can provide care teams with a better view of what has occurred, what should be done next and who is responsible for the next action. This is especially helpful if multiple members of a care team are involved in the care of a patient.
Coordinating Care between office visits
Much of the management of chronic disease happens between visits. Patients could have issues with the medication, have a symptom change, not be able to get from place to place, or may not be able to follow the treatment plan without having to make another appointment to the office right away.
A CCM platform can assist care teams with a consistent outreach schedule and track meaningful interactions. If concerns arise, staff may be able to refer them to a set escalation structure, rather than in a call note.
Supporting Medication Management
The more chronic conditions a patient has, the more complex the medication. A patient can receive more than one prescription, with varied dosing instructions, prescriptions that need to be refilled, and instructions from more than one provider.
Medication-related information can be organised and issues can be detected through software which can be helpful for care teams during the interactions with patients. It is not meant to take the place of clinical judgment, rather it provides staff with a more structured approach to identifying issues around adherence barriers, medication concerns and situations that should be reviewed by the provider.
How Software Improves CCM Program Efficiency
One of the biggest advantages of technology is that repetitive jobs can be automated. This is more relevant the more students that enroll. A workflow that works perfectly with 30 patients can be challenging with the addition of hundreds of patients to repeat outreach and record-keeping every month. Automated task assignments, reminders, patient lists, documentation templates, and reporting tools can save care teams time in dealing with administrative details.
Enabling Medicare CCM workflows
There are tools, like technology, that can assist and support organizations to operationalize CCM; however, a Medicare-compliant service does not rely exclusively on technology. Providers need to be familiar with, and comply with, relevant CMS patient eligibility, consent, care planning, documentation, billing, and other conditions of coverage.
Under general supervision, CMS has identified specific time-based CCM codes for applicable clinical staff services. There can be changes in current requirements and reimbursement policies, so practices should always confirm the rules that apply to them and their billing model.
Connecting CCM With Remote Patient Monitoring
CCM and RPM are two different components of chronic disease management but they can work together. The key difference is that CCM is about coordinating and managing care and RPM gathers health information from patients outside the healthcare environment via connected devices.
For instance, an individual with hypertension can enroll in CCM for education, medication support, and care coordination, and RPM will offer frequent blood pressure readings. If the workflows are properly linked, care workers are able to use objective data in conjunction with patient-reported data to gain a clearer picture of the change in patient’s condition.
How to Choose the Right CCM Platform
Healthcare organizations should assess the technology and a vendor’s ability to support real-world clinical operations prior to entering a contract.
Consider these factors:
- Check for EHR integration: Make sure the system is compatible with your current systems.
- Simplicity: Ensure that the care coordinators can perform simple operations without causing much complication.
- Patient engagement: Analyze the communication channels and personalization options that are available.
- Care plan management: Ensure care plans may be amended and retrieved as necessary.
- Documentation: Assess the availability of resources to and by staff for recording meaningful CCM activity.
- Escalation: How emergencies and/or clinically significant issues are conveyed to providers.
Why Tellihealth Is a Strong CCM Solution
Tellihealth is a combination of chronic care management (CCM) technology and care-management support. The signalCCM solution is engineered to assist healthcare organizations to coordinate patient engagement, care workflows, documentation and communication in an existing healthcare environment.
This type of model may be beneficial to practices that choose not to create all of the CCM functions in-house. Tellihealth’s solution doesn’t treat technology as an application; it’s using technology and humans together to enable organizations to run and scale their chronic care programs.
Conclusion
The proper software can help healthcare organizations establish uniform procedures for care coordination, communication with patients, documentation, and follow-up. Being the platform with the most features is not the only criterion for choosing a practice EHR. Practices should focus on the platform’s capabilities to integrate with their systems, ease of use, care-plan management features, escalation workflows, security, reporting and scalability. For organizations looking for CCM technology and care-management services, Tellihealth is a very good option, and can be expanded to other care-management programs.
FAQs
Is a CCM software the replacement of an EHR?
No, CCM software does not replace an EHR, it works in conjunction with it. Integration can enable care teams to seamlessly manage chronic care workflows but retain critical clinical data in current healthcare systems.
Will CCM software be of assistance in Medicare billing?
CCM software can assist with structuring documents and processes for appropriate Medicare CCM services. Using a platform does not mandate billing eligibility, and providers are still subject to the existing CMS requirements.
What are the factors to take into account when selecting the platform for the CCM?
When it comes to EHR integration, usability, patient engagement, documentation, management of care plans, escalation procedures, analytics, security, scalability, and vendor support, these are all factors that should be considered by healthcare organizations.