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How Chronic Care Management Makes a Difference for Your Patients—and Your Practice



Who Are the Patients You Worry about Most?

“Everyone should have an appointment,” a wise internal medicine physician told me once early in my career as a practice manager, “Either for a follow-up or a physical.”

The majority of the patients in our practice had multiple chronic conditions: diabetes combined with hypertension, or diabetes with COPD—you name it. He generally wanted follow-up appointments every three months, but he worried about his patients in between visits, too. Would they take the medications prescribed? Would they test and report their blood sugar and blood pressure to catch issues before they got out of control? Would they actually see the specialist he recommended?

What Is Chronic Care Management?

Enter Chronic Care Management (CCM) services. In January 2015, the Centers for Medicare & Medicaid Services (CMS) introduced billing codes that cover many of the types of activities being done between appointments in the practice. The codes cover care for Medicare patients with two or more chronic conditions and require at least 20 minutes a month of phone or in-person contact between regular office visits.

Along with increased revenue from billed services, CCM has a number of positive outcomes, recently highlighted in a report by Mathematica Policy Research, including:

  • Improved patient satisfaction; patients feel cared about
  • Increased compliance with recommended medications and therapies
  • Fewer hospitalizations and emergency department visits
  • Improved quality metrics
  • Less clinical staff time spent on routine calls

The service is perfect for patients you worry about the most. It’s the answer to, “What happens to them in between appointments?”

How Does Chronic Care Management Benefit Patients?

We’ve all seen it: Patients get behind in the management of the day-to-day details of their care. Doing it all by themselves can seem like a Herculean task, especially when they don’t feel good already. They don’t keep up with their medications, or maybe they forget to test their blood on schedule. Perhaps they don’t have transportation for that specialist appointment or can’t afford their medications.

Where does it lead? Missed appointments, ER visits, and hospital stays. Could we help these patients avoid all that with a phone calls between visits to help them stay on top of their care? The data says yes. Several studies have shown that care between appointments makes a difference. For example, the authors of a January/February 2009 Health Affairs article said, “We found that patients enrolled in [Chronic Care Management] programs using multidisciplinary teams … had significantly fewer hospital readmissions and readmission days than routine care patients had.”

Patients who receive CCM services are healthier, and they’re happier. They feel cared about by the doctor who recommended the service. They see the Care Coordinator who makes the calls as an advocate, and they don’t feel alone.

Chronic Care Management promotes a collaborative discussion. In short, it’s teamwork, and the patient is part of the team.

Roxanne Thacker, Director of Managed Clinical Services at Mingle Heath, has been working with some patients in the role of Care Coordinator for more than eight years. “We feel like a team,” she said. “The Care Coordinators are enriched by the work, and the patients are so happy to have someone who cares about them call them on a regular basis.”

“I just love having someone call me and make sure I’m on track with all my medical stuff.”

Mary J.—a patient that Thacker works with—said, “I just love having someone call me and make sure I’m on track with all my medical stuff. It’s so overwhelming, and having a helper makes me feel more sure of what I’m doing. They have made it easy to stay on top of it all!”

How Does Chronic Care Management Benefit Your Practice?

Chronic Care Management translates directly to higher practice revenue, and it’s nice to get paid for something the clinical staff is already doing. Patients are happier and feel cared about by their provider.

Practices also see improved quality metrics, which are increasingly important with both commercial and Medicare value-based contracts, and MIPS and MACRA incentives.

Partnering to provide CCM Services—Mingle Health Can Do It for You

Without dedicated staff to do the work, it can be difficult for practices to provide focused, consistent between-appointment care by phone or in person. Keeping track of time spent, making sure it adds up to the required 20 minutes, is cumbersome and distracting. That’s where Mingle Health Chronic Care Management managed clinical services come in.

How Chronic Care Management as a Service Works

Step 1
You hire our expert clinical team to manage your patients with multiple chronic conditions.

Step 2
You enroll your eligible patients in Chronic Care Management services.

Step 3
We call the patient for an initial consultation, then work with you to create a patient-specific care plan for each patient. We function as an extension of your practice.

Step 4
We call your patients every month. They’re healthier and happier, and you worry less. Your staff also spends less time on prescription refill and other routine calls, because we’re taking care of that for you. We document our calls in your EHR each time. You can review patient progress at any time.

As a result, you’ll see your quality metrics and patient outcomes improve, and you’ll increase your revenue at the same time!

Case Study

A perfect example is a primary care practice, with ten providers, was concerned about their patients with diabetes whose A1cs were out of control. This metric was also holding them back from being successful under value-based contracts. Just five of the providers were convinced that CCM could help.

In March 2018, Mingle Health started with this practice’s patients with uncontrolled diabetes. Kent was a patient who had struggled to manage his diabetes for years. He had stopped testing his blood sugars because nothing seemed to be working. He was dubious that the CCM service his doctor offered could make a difference, but he agreed to participate. After a few months, he reported that he liked having someone check in with him and help manage the details of his care. At the six-month mark, Kent’s A1c had decreased by almost three percentage points.

At the end of nine months, based on the results that the first five providers were seeing, the remaining five providers all started referring patients.

We are thrilled here at Mingle Health that we can offer this service to our primary care practices. Roxanne Thacker concludes, “The Care Coordinators at Mingle Health love their work, and the patients love the Care Coordinators. Patients are healthier, practices are more profitable, and providers are more efficient. It doesn’t get better than that!”

Chronic Care Management for your Patients

Interested in learning more? Talk to an expert about how we can manage Chronic Care Management as a Service for you. Call 866-359-4458, or get in touch here. One of our experts will answer your questions and get your practice started.


Webinar: Benefits of Chronic Care Management

Watch this webinar with Dr. Dan Mingle to learn all about Chronic Care Management and the benefits to your patients.

Watch Now
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