Chronic Care Management Workflow Reimagined
Chronic Care Management (CCM) requires proactive planning, coordination of care, and continuous assessment of health outcomes.
A well-designed Chronic Care Management (CCM) workflow is critical for enabling healthcare providers to work efficiently and effectively.
Components of a Robust CCM Workflow
- Identifying Patients
Practices should begin by identifying patients eligible for CCM services. Patients with two or more chronic conditions expected to last at least 12 months and/or are at significant risk of hospitalization or worsening health status are prime candidates for CCM through Medicare and Medicaid. Ideally, this system should be automated to assist in ensuring the right individuals have access to comprehensive care.
Learn more about what conditions qualify for CCM here.
- Crafting Care Plans and Setting Goals
As each patient’s case is unique, personalized care plans and goal-setting is the foundation for their long-term care. This must be done in conversation with the healthcare provider, patient, and caregivers. Collaborative, tailored care plans with achievable health goals encourage active patient involvement and instill a sense of ownership for their wellbeing.
- Patient Engagement and Education
Previous studies have shown that health literacy and patient engagement play an essential role in improving health outcomes for individuals with chronic disease. Educating patients about their condition and involving them in decision-making empowers them to take charge of their health.
- Consistent Follow-up and Monitoring
Regular communication and follow-up consultations are vital to chronic care management. It may be helpful to create a schedule of check-ins between the patient and providers. By tracking patient progress and addressing concerns in real-time, providers can ensure continuity of care and intervene when necessary.
- Utilization of Technology
Providers can optimize Electronic Health Records (EHRs) to track clinical metrics, identify care gaps, and facilitate evidence-based decision-making. Beyond EHRs, there are specialized patient management software platforms dedicated to managing CCM. These platforms can automate patient check ins to collect routine information about symptoms, medication management, care plan adherence, and other valuable metrics. Check-ins can occur over phone call, text message, or email.
- Collaboration with Specialists and Other Healthcare Providers
Often, patients with multiple chronic conditions are also seeking care from various medical specialty practices that are not adequately aware of each other’s care. According to a study in the Journal of the American Medical Association, this can lead to contraindicated treatments and miscommunication about patient care.
To screen for this, incorporate questions regarding other sources of current care into initial patient intake forms and regular office visits. Establishing communication and information exchange between these various specialty practices allows for integrated care, reduces redundancy, and increases higher patient satisfaction.
It is important to remember that establishing an effective CCM workflow is iterative and unique to your practice and your team. While it is helpful to seek best practices, the best CCM workflow is the one that is tailored to the needs and goals of your practice.
Quadrant Health is a comprehensive CCM platform that allows practices to personalize and automate patient check-ins using generative AI.
Learn about the 4 steps to get your practice started with CCM, to provide better care for your patients while increasing revenue.