Managing chronic conditions effectively requires more than periodic office visits. While each provider may be looking for different features, the ideal piece of chronic care management software for practices will be a single platform that offers care coordination, patient engagement, documentation, workflow support, and reimbursement readiness. Chronic Care Management (CCM) is a Medicare service that is covered for eligible patients who have two or more chronic conditions that are likely to continue for 12 months or longer (or until death).
That model should be easier to do with the software, not another administrative burden. The best chronic care management software assists teams with ensuring individual care plans, documenting qualifying work, patient communication, inter-clinician coordination, and uncovering problems that require resolution between visits. Measurable goals, planned interventions, medication management, symptom management, coordination with other providers, and periodic review are all part of comprehensive care planning, according to CMS.
When considering a dashboard for healthcare organizations, it’s not just about having all the bells and whistles, but about having technology that suits the real clinical workflow. The right platform should enable a care team to seamlessly translate patient data into action and to maintain an efficient and manageable documentation and operational workflow.
What To Look For In The Best Chronic Care Management Software
The most successful systems align with the clinical and administrative needs of CCM, and not just as a messaging software. Healthcare leaders should consider the following vendor capabilities when evaluating a vendor:
- Patient engagement: Facilitate regular engagement via viable means of communication.
- EHR integration: Share pertinent patient information with the current EHR.
- Documentation support: Record care activities and necessary information in a systematic process.
- Care coordination: Ensure alignment of primary care teams, specialists, caregivers and other players.
- Task management: Assign work, follow up and surface overdue tasks and manage active patients.
- Scalability: It can grow without the need to redesign the workflow.
A good test is to request a vendor to show a patient journey and not a product tour. Provide the representative with a patient who has diabetes, hypertension, and heart failure and who is not attending follow up appointments and has a concern about medications. The best platform should demonstrate how a patient is identified, then contacted, documented, escalated and followed up without a number of staff having to piece the story together across multiple systems.
The Impact Of CCM Software On Clinical Workflows
CCM is essentially a longitudinal service. One week the patient may require education or follow up of symptoms, another week for medication review and a third week for help with a specialist visit. CMS defines CCM as a patient having multiple chronic conditions who are at high risk of death, acute exacerbation or decompensation, or functional decline
Identify And Enroll Patients
A useful system will assist teams to identify suitable patients and to introduce them to a structured workflow. However, this is not sufficient for eligibility, as patient participation, clear goals, and consistent engagement are also needed to achieve successful CCM.
Actionable Care Plans
Care plans should not be a one off creation, but frequently reviewed documents. Good software allows you to see and trace your goals, the interventions that are planned, the medication, the symptoms, and the follow up activities all in one place where those who have the responsibility to act on them can see them.
Documentation Without Excessive Manual Work
One place where poorly designed CCM workflows can eat into staff time is documentation. CMS has set both time and code requirements for a few of the CCM services, such as CPT 99490 for the first 20 minutes of clinical staff time and add-on code CPT 99439 for every 20 minutes of time spent after that.
It is important that the software system should facilitate clinical judgment and make it easier to capture the activities accurately. Work should be automated to make it easier to work and less repetitive to enter data, not to make it easy for staff to enter data on care that did not happen.
Why EHR Integration Is More Important Than A Long List Of Features?
If a CCM platform provides dozens of features, and establishes a second clinical workspace, the platform is not performing well. Integration is important since clinicians already rely on the EHR to document patient information, and disjointed workflows can result in duplicate data entry, lost information, and unnecessary clicks.
Tellihealth’s CCM solutions are designed to seamlessly integrate with current EHR platforms and facilitate automated documentation and proactive outreach, the company says. The Evelyn platform seamlessly supports CCM and RPM, integrates with EHRs, provides AI driven insights, and offers patient support.
The real test is does interoperability make the workflow better. Check if there is spread of information to areas where staff work, if the changes are seen by the staff who need them and if the system actually saves time in administration.
Benefits of Choosing a Purpose-Built CCM Platform
When implemented around measurable workflows, a dedicated CCM solution can create value for clinicians and patients.
- Improved follow up consistency: Tasks and reminders can minimize missed contacts.
- Improved patient engagement: Patient organization of communication ensures a connection between visits.
- Improved care co-ordination: Information is shared with teams so that they can co-ordinate medication changes, specialist care, education and follow up.
- Improved visibility of leadership: Reporting can indicate if the CCM program is active and scalable.
- Value based care support: Longitudinal information enables teams to address issues before they escalate.
All too often the operational payoff is overlooked. If the program is one that generates a lot of reimbursement, but is time intensive for the care manager, then it may not be feasible for care managers with large patient panels.
Evaluating CCM Software Vendors
Evaluation can save a technology decision, when it is done in a disciplined manner. Rather than just looking at screenshots and the number of features, health care executives should test each system against real world workflows.
- Map the existing process of CCM: Describe the process of identification, enrollment, contacting of patients, documentation of patients, escalation and review of patients.
- Perform a live patient scenario: Take an anonymized case of a patient with multiple chronic conditions and a number of care needs.
- Measure staff effort: Monitor clicks, duplicate entry, handoffs and time to complete common activities.
- Verify EHR connectivity: Specifically, ask what information is shared, how it is displayed and how it is updated.
- Review reporting workflows: Verify that it includes all the documentation and operational procedures necessary for your organization.
This is a frequent issue, as software that seems efficient during the sales process can be problematic when deployed in clinical settings. The best system is one that makes the regular tasks easy, and also addresses any exceptions in an elegant fashion.
The Reasons For Choosing Tellihealth For CCM Programs
Unique to Tellihealth is that their CCM solution integrates software, workflow and human care, not just technology. It focuses on proactive outreach, care coordination, documentation automation, integration with EHR systems, and dedicated care teams with its signalCCM solution.
Another distinction is its built-in CCM and RPM method. When remote physiologic data and longitudinal care management are linked, teams can create a more holistic view of patient needs and better defined escalation pathways. Additionally, Tellihealth has been steadily building up its platform and interoperability features, such as more robust integration with EHRs and features designed to enhance clinicians’ productivity.
Conclusion
Tellihealth is a good option since its signalCCM service offers technology, clinical support, EHR integration, and an integrated RPM option. Tellihealth can serve as the platform to develop and expand a modern CCM program, providing scalable, patient centric chronic care for organizations.
FAQs
What Is Chronic Care Management Software?
Chronic care management software is a technology used to coordinate and document chronic care provided to patients. It usually facilitates care plans, patient outreach, task management, documentation, reporting and care coordination.
Who Can Benefit From CCM Software?
CCM software can be utilized by primary care practices, specialty practices, multi specialty groups or health systems to coordinate ongoing care for eligible patients. It is especially helpful for companies dealing with groups of individuals that have various chronic ailments.
Does The CCM Software Facilitate Claims With Medicare Reimbursement?
While there are CCM software solutions that can help with the documentation, time tracking, and workflow for covered CCM services, software alone is not the key to reimbursement. Organizations need to be in compliance with applicable CMS requirements and accurately document and bill eligible services.
What Does CCM Vs RPM Mean?
CCM emphasizes continuous care management, coordination and support of the patient while RPM involves connected devices to gather and transmit health information and data for clinical review. They may be used in conjunction with one another if a patient would benefit from both the longitudinal coordination and frequent physiologic data.
