Chronic Care Management

Today’s healthcare systems see more patients with multiple chronic illnesses. An expert solution drawing on two decades of clinical support experience maximizes CCM enrollment, increases revenue, and improves health outcomes.

In-Person Support to Increase CCM Enrollment.

Our Chronic Care Management navigators work as an extension of your internal staff to enroll and manage CCM patients. From health coaching, routine check-ins, and on-call assistance, we'll keep patients engaged and proactive throughout their treatment plans. While front office staff may be bogged down with ancillary duties, trained navigators ensure patients connected to the proper local resources, and that lab or other critical needs are met. CareThrough embeds in your practice, working elbow-to-elbow with providers so that patients keep appointments, have assistance with transportation, and receive immediate care if necessary.

We understand the importance of preventing care gaps, both in terms of revenue and outcomes. By regularly scanning files for changes and improvements in the care setting or at home, our navigators update documentation and correct chart inaccuracies. Unaccounted Medicare codes, such as CPT 99490, can be costing you millions in lost federal funds. Our Care Navigators are specially trained in Medicare coding and embedded into your CareTeam to ensure accurate capture and documentation of services that your team is already performing. Let us maximize your CCM program to increase revenue, while also strengthening patient outreach beyond the care setting to improve overall health outcomes.

The CareThrough Approach

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Our CCM Navigators work as an extension of your internal staff to provide education, coaching and periodic follow-up calls that can lead to long-term, lasting patient outcomes. With a specialized chronic care management program, your patients will receive comprehensive care plans and ongoing support where and when it’s needed. Through routine check-ins and on-call assistance, patients are supported in a wide range of needs including:

Population health management

We help control costs while improving population outcomes through our analytics, care management and more.

Developing customized care plans

Navigators connect with patients to schedule appointments, monitor adherence, and even identify at-risk patients for customized care.

Top-of-license efficiency

Our navigators function seamlessly within your practice to enable providers to work on tasks ideally suited for their clinical expertise.

Connecting to local resources and facilities

Tracking down the right local resources requires time that overworked providers seldom have. Our navigators can connect patients to the appropriate accessible facilities.

Ensuring labs and other critical needs are met

Routine check-ins and on-call assistance closes the care gap where labs and other needs are concerned.

Higher reimbursement rates

Our navigators are experts on CMS documentation guidelines that can yield greater revenue.

Ongoing assistance to help self-manage conditions

We empower patients to achieve their health goals by coaching them on better nutrition and compliance with exercise or other related plans.

How It Works

Don’t let patients slip through the care gaps. We connect technology and care coordination tactics to proactively reach at-risk patients. Both on-site in the care setting or at home, Navigators connect with patients to schedule appointments, monitor adherence and so much more. Get access to critical information in less time, while navigators partner with patients to manage their care.

Navigators are embedded into your practice

Working elbow-to-elbow with your care team
Freeing providers to work top-of-license

Let the Navigators connect with your patients

Successfully enroll high numbers of patients
Expand your CCM program with minimum investment

Navigators coordinate to empower patients

Keep a watchful eye on changes and improvements
Constantly updating charts to correct inaccuracies
Empower patients to keep appointments, organize transportation, and receive immediate care if necessary

Our nationwide population is aging, which means Chronic Care Management is an important opportunity to benefit patients as well as providers engaged in the shift to value. It is a better use of your resources to partner outside your system with expert navigators trained to enroll a higher numbers of patients and expand your CCM program. Our team has clinical support experience and a valuable understanding of those living with two or more chronic conditions. Navigators accurately document and monitor customized care plans, which streamlines revenue management and improves patients’ lives.

Care Navigators

As healthcare business models evolve, so should care teams.

Patients who are paired with Care Navigators report feeling less anxiety, and an increased ability to self-manage their conditions between visits. And providers report increased job satisfaction from improved efficiency, and knowing their patients have access to care teams, and strategic support.

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Chronic Care Management

With an increased aging population managing two or more chronic illnesses, extending your care teams’ ability to communicate with patients is critical. We take a strategic approach to helping patients chart a path towards their health goals, while self-managing their chronic conditions between clinical visits.

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AI Chatbots

We deliver a robust AI Chatbot solution to help manage and sustain effective communication with patients. Care teams implement the conversational text messages and customize patient communication to deliver high quality care.

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Nurse Care Team Assistants

While nurses comprise the largest healthcare workforce, many suffer in silence from burnout and decreased job satisfaction. Our Nurse CTAs combat burnout with strategic support. From documenting patient encounters to monitoring vital signs, CTAs ensure nurses work top-of-license. CTAs close critical gaps in the care continuum and provide nurses with the added bandwidth to focus on critical care.

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Scribe Services

There’s a reason why we’re the nation’s most frequently used scribe company: we offer professionally trained medical scribes to meet the specific needs of our clients. We offer a variety of scribe programs, as well as technology and personnel solutions that address revenue cycle management, the transition to value-based care, and more through our HealthChannels family of companies.

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Referral Management

Referrals scheduled by navigators in the clinical setting builds long term, patient care integrity across the care continuum. With the authority, along with the provider to search for specialists in network, navigators assess their schedules, and ensure appointment compliance.

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