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Chronic Care Management

The Current State of Chronic Care

In America’s fragmented healthcare system, millions of people with chronic conditions desperately need coordinated care. Chronic conditions account for nearly 86% of U.S. healthcare spending and continue to rise.

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What is Chronic Care Management (CCM)

CCM is care coordination services done outside of the regular office visit for patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

Examples of chronic conditions include, but are not limited to, Alzheimer's disease and related dementias, arthritis, asthma, atrial fibrillation, autism spectrum disorders, cancer, cardiovascular disease, chronic obstructive pulmonary disease, depression, substance use disorders, diabetes, hypertension, ...

Under CCM, the patient's care team can bill for time spent managing the patients' conditions. This includes formulating a comprehensive care plan, interactive remote communication and management (usually over the phone), medication management, and coordination of care between providers.

SimpleCare Solution difference

Restricted time and practice resources
Uncertain financial outcomes
Concerns about red tape and changing CMS regulations
Investing in technology is essential

Challenges of Implementing CCM for Providers and Our Solutions

Barriers to implementing CCM for Healthcare providers fell into four categories:
Time Constraints

Chronic care management requires more time and attention as it involves ongoing monitoring and coordination of care for patients with long-term conditions. Providers may already have a busy schedule and find it challenging to allocate additional time for these services.

Resource Limitations

Implementing chronic care management may require additional staff, technology, and resources, which some smaller practices or healthcare facilities may not have readily available.

Reimbursement Challenges

The reimbursement process for chronic care management services may be complex and time-consuming, leading some providers to opt for more straightforward billing options.

Administrative Burden

Chronic care management involves documentation, coordination, and communication with patients, caregivers, and other healthcare professionals. The administrative burden associated with these tasks can be overwhelming for some providers.

Simple Care Medical Services CCM solutions enable physicians to deliver the highest quality care for patients with chronic conditions.
  • Simple Care Medical Services’ Chronic Care Management (CCM) telehealth solution seamlessly integrates with physician practices and healthcare systems to provide care coordination, medication management, and consistent patient engagement.

  • Simple Care Medical Services alleviates physician workload and improves MIPS and APMs quality scores.

Integrating our CCM solution with your practice enable your healthcare providers to overcome these challenges and to deliver the highest quality care for your patients with chronic conditions.

At SimpleCare Medical Services, we handle comprehensive management of CCM from start to finish including care coordination, medication management and consistent patient engagement.

Immediate benefits for providers
  • Alleviates Medicare paperwork and practice workload

  • Added revenue stream

  • Actionable clinical intelligence

  • Increased patient loyalty

  • Improved quality measures

  • Empowering physicians and providing them with support

CMS quality measures impacted by our CCM

55
QUALITY
27
IMPROVEMENT ACTIVITIES
5
PROMOTING INTEROPERABILITY
1
COST
6
PATIENT/CAREGIVER EXPERIENCE
6
PREVENTATIVE HEALTH
4
CARE COORDINATION/PATIENT SAFETY
3
AT-RISK POPULATION
1
ADHERENCE TO CARDIOVASCULAR MEDICATIONS
1
ADHERENECE TO CHOLESTEROL MEDICATIONS (STATINS)
1
ADHERENCE TO HYPERTENSION MEDICATIONS (ACE-I/ARB/DRI)
1
ADHERENCE TO DIABETES MEDICATIONS
1
COMPREHENSIVE MEDICATION REVIEW (CMR) COMPLETION RATE
1
STATIN THERAPY FOR PATIENTS WITH CARDIOVASCULAR DISEASE (SPC)
1
STATIN THERAPY FOR PATIENTS WITH DIABETES (SUPD)

Join the expanding practices utilizing Simple Care Medical Services to enhance patient outcomes.

Schedule A Demo
  • No upfront costs required

  • We take on the workload

  • Decreased non-billable time.

  • Automated patient eligibility verification

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