Chronic Care Management Process

Eligibility Determination/ Risk Stratification

Data from a Physician’s EMR or billing system is uploaded via secure link into the PCCM cloud based software and all qualifying Medicare Patients (Medicare Enrollees with 2 or more qualifying chronic conditions) are identified using this Physician Supplied data and then sorted into high, medium and low risk levels using their Hierarchical Condition Category (HCC) score.

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Patient Consent/On-Boarding

PCCM provides contracting Physicians and their office staffs with assistance on-boarding new CCM Enrollees. PCCM will mail personalized, program introductory letters to all identified, eligible Patients; will assist Physician office staff to contact Patients by telephone to introduce the CCM program and, if requested, schedule office visits for those Patients not seen by their Physician in the last 90-days. Where Patients have had an office visit in the prior 90-days and have a current, Physician prescribed plan of care, PCCM can electronically capture the Patient’s consent for CCM services provided the Physician has previously discussed Chronic Care Management with their Patient. PCCM provides Physician practices with all necessary Patient enrollment and education materials, including privacy and consent forms and initial copies of their personalized plan of care. Patients may log onto PCCM’s secure, electronic portal to receive and sign all materials and forms or receive and sign hard copies while at their Physician’s office. PCCM’s Patient Consent materials specifically address the nature of CCM; how it’s accessed, that only one provider can provide CCM for a Patient at a time, that the Patient’s health information will be shared with other providers for care coordination purposes, that the Patient may stop CCM at any time by revoking their consent, and that the Patient is responsible for co-pays and deductibles (Co-pay for CCM is estimated at $8.07 per month and may be covered in the same manner as copayments and deductibles for regular office visits for Patients with Medi-Gap policies).

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Care Plan Personalization

PCCM works with the Patient to personalize their Physician prescribed care plan and to build in personal motivators, identifiable goals and track able outcomes and time tables. This care plan will be updated intermittently by PCCM and fully reviewed at least annually by the Patient’s Physician. The care plan assesses the physical, mental, cognitive, psychosocial, functional, and environmental needs of the Patient. Specifically the care plan should include a list of current practitioners regularly involved with the Patient; the evolving status of the Patient’s chronic health conditions, notation of cognitive limitations or mental health issues that impair self-care, assessment of the Patient’s preventive healthcare needs, notation of the Patient’s preferences, choices and values that affect the care plan, a self-identified problem(s) list, expected outcomes and prognosis, measurable treatment goals, symptom management strategies and planned interventions, community and social services’ needs list, notation of care coordination services required, documentation of medication self-management including the review of the Patient’s current medication list, reconciliation thereof, assessment of adherence with prescribed medication regimen(s) and review for potential interactions and allergies.

20 Minutes of Chronic Care Management Services Monthly

PCCM clinical staff will provide each enrolled Patient twenty (20) minutes of non -face to face Chronic Care Management Services monthly and which may include  (1) on-going medication reconciliation and oversight of the Patient’s self-management of medications; (2) ensuring the Patient is receiving recommended preventive services; (3) on-going monitoring of the Patient’s condition (physical, mental, social); (4) providing education and addressing questions from the Patient, their family, guardian, and/or caregiver(s); (5) providing remote monitoring of Patient physiological data; (6) identifying and arranging needed community resources; and (7) assisting the Patient and their Physician in on-going communication with other community service providers utilized by the Patient.

Service Coordination/ Referral

PCCM will coordinate as necessary with home and community based service providers that help to meet the Patient’s psychosocial needs and functional deficits including providers of home health, hospice, outpatient therapies, durable medical equipment, transportation and nutrition services and will assist in providing referral to other healthcare products and services at the direction of the Patient’s Physician.

Post Emergent Care Consultation/ Care Transitions

PCCM will provide follow-up consultation with all Patients after any known emergency room visits or inpatient stay and will provide, post discharge from an inpatient facility, care transition services for Patients as necessary.

CCM Software

Our CCM Software is a cloud-based, modular technology platform. It was developed to meet all the electronic care plan requirements for CPT code 99490. The intuitive design helps providers, care teams and administrators leverage a sophisticated engine to identify and manage patients with 2+ chronic conditions. The software technology is the ideal platform to create and manage care plans for these identified patients. It includes feature rich capabilities beyond typical electronic care plan software.

24/7/365 Clinical Staff Availability