Better Care for At-Risk Patient Populations

Chronic Care Management (CCM) is non-face-to-face care provided to patients with multiple chronic conditions to provide continuity of care and monitoring them in a timely manner. The patients are followed regularly, and their needs are met consistently. It leads to identifying the barriers to care and solving the care accessibility. The goal is to prevent worsening of chronic medical conditions. This program requires patient consent and specific disease burden to enroll in CCM care.

Process

  • Identify eligible patients and enroll to CCM program during office visits or non-face-to-face visits
  • Evaluate the Patient and develop a patient disease specific Care Plan by the physician
  • Employ an integrated time tracker
  • Improve health care outcomes and experience.

Did you know that more than 60% of Americans suffer from at least one chronic disease, with 40% of those battling two or more chronic diseases? For patients like these, chronic care management (CCM) can dramatically help them sustain better health for a longer period of time. Receiving coordinated chronic care services outside of a physician’s office allows patients to engage and access the valuable, multi-disciplinary medical support and services that can positively impact their health while reducing the expenses and lag time associated with visiting multiple clinicians across multiple specialties more readily. Clinician and organization efficiency can also improve as this approach allows practitioners and their teams to provide excellent care while better ensuring they have time available for other care demands and needs.