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Chart-Markers: The CCM Patient Journey

If you’re considering offering Medicare’s Chronic Care Management program to your patients, you probably have questions about the journey a CCM patient will go through. CCM can help increase practice revenue and close gaps in care, but these benefits are only meaningful if patients have a positive experience. 

At ChartSpan, we call our patient roadmap “Chart-Markers.” Our clinical team uses Chart-Markers to guide patients’ flow through a structured CCM program and to ensure they have the support they need to manage their chronic conditions. Conversations with their care coordinator lead to assessments and screenings that uncover where a patient may need help, and care coordinators provide resources to patients who need them. 

Chart-Markers is not a rigid system, since every patient’s journey varies based on their individual needs. But the structured clinical roadmap helps patients consistently work on relevant care goals, so they can improve their health outcomes and manage their chronic conditions. 

Want to learn more about how Chart-Markers works? We’ve put together this framework to show the patient’s journey.

Step 1: Enrollment Call 

Every patient journey begins with their enrollment call. Enrollment specialists must follow CMS guidelines for the call and must explain: 

• What Chronic Care Management is
• That patients may have a copay
• How participants can unenroll at any time
• That patients may only enroll under one provider

The enrollment specialist must receive verbal consent from the patient that they want to enroll, record the call, and archive the recording for 10 years. 

Step 2: Welcome Call for CCM Patients

Once a patient gives their consent to enroll in Chronic Care Management, they will receive a welcome call from a care coordinator. The care coordinator will review what care management is and get to know the patient and the health outcomes they would like to accomplish.

If patients are ready to discuss their chronic conditions and their care goals, the coordinator can jump into those processes as well. 

Step 3: Discussion of Chronic Conditions

During monthly touchpoint calls, care coordinators engage in an in-depth discussion of the chronic conditions that led to the patient being enrolled in Chronic Care Management. The patient can share how they’re currently managing their conditions, what concerns they have, and what goals they would like to reach. 

For example, a patient with high blood pressure and diabetes might discuss their current blood pressure readings and A1C levels, whether they’re happy with those levels, and concerns about whether they’re eating well or getting enough exercise. This discussion empowers personal care coordinators to write relevant, achievable care goals for patients. 

Care coordinators can also obtain and review medical records from various providers that are involved in the care of the patient. With these records, the coordinator can ensure the patient’s care goals match their provider’s recommendations and meet their current health needs. 

Step 4: Care Goals

Care goals are one of the most vital elements of Chronic Care Management. Every CCM patient will have a few care goals at a time, created by the patient in collaboration with their personal care coordinator. 

Some goals may be introduced by patients first, while others will be suggested by the care coordinator based on the patient’s conditions and current health status. Care goals follow SMART goal standards:

• Specific
• Measurable
• Achievable
• Relevant 
• Time-Bound

For example, a patient with hypertension might set a goal to lower their blood pressure to 130/80 by the end of the month. The care coordinator will record that this goal is related to a patient’s hypertension, then help the patient come up with a plan to achieve the goal. The coordinator might:

• Provide recipes that are low in salt
• Suggest exercises approved by the patient’s provider
• Share stress management techniques

Qualities of an Effective Care Goal

An effective care goal includes: 

• The problem that needs to be addressed
• The goal created following the SMART standard
• Steps that could help the patients achieve the goal
• The actions the patient takes each month
• Evaluations by the coordinator of how well the goal is going
• How often the goal should be reviewed

If a patient achieves their goal, or if a goal becomes irrelevant, the patient and the care coordinator can work together to create a new care goal. If a patient isn’t interested in addressing a particular condition, the care coordinator can also set a goal of educating the patient about their condition and the benefits of better managing it. 

Care coordinators can also serve as health advocates–not only setting goals, but holding patients accountable to them by checking in regularly and offering encouragement or advice. 

Step 5: Assessments

Assessments are an important aspect of Chart-Markers. Care coordinators are trained to provide assessments when your practice asks for them or when patients demonstrate that an assessment might be helpful. 

For example, if a patient mentions they fell recently, the coordinator should conduct a fall risk screening. If the patient seems confused during the call, the coordinator might perform a cognitive assessment. 

A CCM program could include assessments for: 

• Cognitive abilities
• Functional skills
• Durable medical equipment needs
• Medication adherence
• Condition awareness
• Daily health
• Fall risks
• And more

Based on the assessment’s results, the care coordinator can determine whether the patient needs to see their provider and what educational content or video resources could help them manage their health. 

Step 6: Social Determinants of Health

Social Determinants of Health (SDOH) have a dramatic impact on patient health, accounting for roughly 50% of county-level variations in health outcomes. SDOH has therefore become a priority for many practices. In response, CCM vendors have embraced SDOH screenings and started providing socioeconomic resources. 

During an SDOH screening, care coordinators ask whether patients have access to: 

• Clean, safe housing
• Reliable transportation
• Work, volunteer, or social opportunities
• Nutritious food
• Safe relationships
• Financial resources
• And more

If a patient is facing SDOH hardships, their care coordinator can connect them to local resources like housing agencies, car services, food pantries, grocery delivery, and support groups. The care coordinator can also report to your practice on where the patient needs support and follow up with the patient each month to ensure they’ve found the resources they need. 

Step 7: Quality Improvement

Quality scores are critically important to many healthcare practices, especially those who are members of ACOs or have entered into value-based contracts. To increase their quality scores, providers need patients to complete their screenings and make appointments to close care gaps.

Chronic Care Management makes closing care gaps easier and faster for overworked providers. At your practice’s request or based on patient needs, care coordinators can perform assessments for:

• Mental health
• BMI
• High blood pressure
• Influenza immunizations
• Pneumonia immunizations
• Breast cancer screenings
• Colorectal cancer screenings
• Diabetic eye exams
• Diabetes hemoglobin A1C control

Identifying and Closing Care Gaps

If a patient reports that they’re missing screenings, exams, or immunizations, the care coordinator can share education on why specific forms of preventive care are important. When a patient agrees they need the screening, the CCM coordinators can quickly reach out to your practice to schedule it.  

Coordinators can also note when patients have received immunizations or screenings at pharmacies or mobile screening facilities.  They can capture information about where and when the screening took place and then share this information with you to help close the care gap for your practice. 

Additionally, CCM can aid patients struggling with A1C levels, high blood pressure, BMI, or other health indicators. Care coordinators can make appointments at your practice or give the patient strategies and resources to improve their health at home. 

Finally, with growing rates of loneliness and depression among older adults, mental health screenings have become a critical component of CCM. If care coordinators notice a mental health concern after a screening, they’ll alert your practice about the patient’s mental health challenges and direct them to resources like therapists and support groups. 

Improving Quality Scores

Identifying and closing care gaps plays an essential role in improving patients’ health and in increasing practices’ quality scores. The average ChartSpan CCM customer managed to earn an 88.4 Merit-Based Incentive Payment (MIPS) score from Medicare, making them eligible for reimbursement increases and payment bonuses. 

While helping patients remains at the core of CCM, increased Medicare revenue can benefit many struggling healthcare practices.

Step 8: Re-evaluating and Adjusting Goals

Every CCM patient’s journey is different. A patient might see dramatic improvements in their condition or experience an emergency that gives them new, more urgent health needs. Sometimes these changing conditions make care goals hard or impossible to adhere to. 

CCM coordinators must be able to to reassess and readjust patients’ care goals as needed. During monthly check-ins, the care coordinator can ask about changes in patients’ health or living conditions and alter the goals and the resources they receive accordingly. 

For example, a patient who has recently suffered a fall might need information on making their home safer or more accessible, even if they were previously focusing on their A1C levels.

Another patient might currently be working on a blood pressure goal but find themselves struggling with loneliness and boredom. The care coordinator would respond to the patient’s needs and search for resources like volunteering or exercise groups in the patient’s city.

A good Chronic Care Management plan includes comprehensive care goals and screenings without sacrificing attentiveness to patients’ needs and the ability to listen. 

Mapping the CCM Patient Journey

While knowing the general roadmap a CCM program will follow is valuable, a good CCM vendor will work with your practice and your patients to provide personalized care. ChartSpan uses Chart-Markers to ensure we meet the most important requirements of a CCM program, like providing care goals, assessments, and SDOH screenings. 

However, our care coordinators are flexible and willing to adjust their monthly check-ins to address quality needs, gaps in care, and, most importantly, any patient needs that arise. Their goal is to ensure your patients are receiving the preventative care they need to live healthier, more fulfilling lives. 

If you’d like to learn more about Chronic Care Management, check out our free guide to choosing the best CCM vendor for your practice.