Virtual care programs are designed to deliver and continue the care patients need especially for the high-cost, high-risk populations who are most chronically ill. The primary goal of virtual care is to improve patient health outcomes by taking into consideration not only the medical but also to the functional and psychological needs of patients.
One such virtual care program is Chronic Care Management (CCM), which ensures continuity of care particularly during in-between office visits. The Center for Medicare and Medicaid Services (CMS) acknowledges the value of CCM by adding incentives to physicians who participate in the program. Providers know of its benefits not just in revenues, but in terms of patient outcomes.
Despite the benefits CCM brings, patient enrollment across the country remains low. The main challenge is how to best inform and help patients understand the value of CCM so they may start to fully participate in it.
Why are patients not participating?
Most patients know little to nothing about the program. Often they do not see its value because they do not understand what CCM is all about. To promote patient awareness, successful physicians develop CCM enrollment strategies following these simple steps:
1. Identify eligible patients from your EMR.
Many EMRs have CCM eligibility reports built in. However, with 70% of Medicare beneficiaries qualifying for CCM, finding eligible patients is not going to be a problem. There will be a sufficient influx of eligible patients to make the CCM program sustainable in the long run.
To recap a previous blog, What is Chronic Care Management?, CMS defines a qualified patient as having two or more chronic conditions expected to last for 12 months at the very least or until the patient’s demise. To ensure the patient’s condition does not escalate, clinicians need to provide wraparound care that looks into the patient’s wellness while ensuring care instructions are strictly followed.
2. Promote awareness by stressing the benefits of CCM.
This will involve conducting outreach campaigns and leveraging patient visits by giving them access to branded brochures or educational posters as a starting point. These campaigns may be remote or only utilized during a patient’s regular office visit.
3. Consistently enroll your patients
During in-office visits, review patients’ programs and describe how CCM can help them. Though time-consuming and resource-driven, contacting every eligible patient is part of the process so that you can better communicate with them as to why they need CCM. The most effective approach is, of course, a more personalized discussion that helps them understand the value of CCM in simple and effective ways.
So what do patients want to know about your virtual care solution? Here are a few tips to help you explain CCM to your patients and increase your patient enrollment in the process.
How to increase Patient Enrollment in your Medicare Chronic Care Management Program?
Why is CCM important to them?
Providers should help patients understand their condition and why they should participate in a care management program. Answering the “Why” ushers in a better appreciation of what CCM offers like a support system or a clinical team at their disposal to assist them in managing their condition(s).
Encourage buy-in and promote engagement by starting with simple benefits like reducing hospitalizations, frequent in-office appointments, and healthcare costs. CCM can help improve quality of life, well-being, and health outcomes for participating patients.
How does CCM Work?
Patients appreciate having a grasp of what is involved in the program like the frequency of calls or check-ins by a member of their physician’s clinical care team. CCM also includes care instructions that they need to comply with. More importantly, patients also need to know how and when they will be billed.
CCM provides patient support outside of the doctor’s office. This support could be a quick response to any of their queries or a medication concern, more efficient coordinated care with other providers or specialists, and 24/7 access to a clinical team.
How CCM works is to make the delivery of care convenient for patients. Patients can receive at-home care, which can be through a telephone or a secure web portal. Naturally, an in-person check-in with a practitioner is still needed, but the majority of the work is done by the clinical team behind the scenes.
How do they qualify?
Patients are eligible if they have two or more of these conditions such as asthma, arthritis, cancer, diabetes, dementia, Alzheimer’s disease, and even mental health issues like depression for example. If qualified, they need to indicate their willingness to participate through verbal or written consent.
By discussing consent with the patients, they know from the onset that they need to actively play their part in this type of care management. Let them know also if there are any out-of-pocket costs that they may need to pay.
To obtain consent, the patient’s medical record must indicate that CCM is available and availed. Other vital information should include cost-sharing, the name of the provider or vendor, and a notice that the patient has the right to terminate the services at any time.
What are the first crucial steps?
For CCM to deliver on its promises, the provider and the patient need to lay out the groundwork. They need to first discuss the patient’s health issues and make a list of the problems including the prognosis and expected outcomes. Based on this list, the provider will lay out the treatment goals, planned interventions, and who will be responsible for each one as well as a symptom management plan.
For optimal care, an effective CCM program utilizes Remote Patient Monitoring (RPM), which leverages digital technologies to capture patient data like vital signs in real-time. Chronic care patients may be given one of these RPM devices to capture the needed measurements that are directly related to their conditions. For truly comprehensive care, the community and social services are also ordered in case they are needed.
Why is Patient Engagement so important in Chronic disease management?
Chronic disease management depends on patients working with their healthcare providers to make lifestyle changes and take an active role in their own care. Patient engagement is essential to successful chronic disease management, yet it can be a challenge to maintain over time.
There are many reasons why patient engagement is so important in chronic disease management. First, when patients are actively involved in their own care, they are more likely to adhere to treatment plans and make the necessary lifestyle changes. Second, engaged patients tend to have better health outcomes overall. Finally, patient engagement can help to reduce healthcare costs by preventing exacerbations and hospitalizations.
There are a few key ways that healthcare providers can promote patient engagement. First, they should provide clear and concise information about the disease and treatment options. They should also involve patients in decision-making as much as possible and encourage them to ask questions. Finally, they should create a support system for patients so that they feel empowered to manage their disease.
Communication is the Key
Many patients often experience a disconnect in between visits with their providers making them unsure about how to proceed with their care needs. Then, add to that the complexity of the medical system that makes it difficult for some patients to navigate. Providers are often expected to be good communicators to bridge this health literacy gap by being in the right position to do so.
To achieve a strong buy-in and enable patients to obtain positive health outcomes through CCM, communication is the key. However, not all providers can be good communicators or have the time, but there are CCM vendors who are.
Ascent Care Partners (ACP) offers turnkey CCM and RPM solutions and provides a comprehensive White-Glove setup for patient education and support. With years of experience in the industry, ACP finds innovative ways to assist you in increasing your patient enrollment and allow your practice to tap into an unrealized and deserved revenue.
