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“CareThrough hired, trained and managed the CCM program Navigators. If we had tried to create an in-house program, it would have been unsustainable with our current staffing model.”
As a health a system in Louisiana transitioned to becoming an Accredited Care Organization, finding support through the process was a key driver to their success. It was a long road, with years in the making. The hospital supported overburdened providers with medical scribes, however they were still unable to fully meet chronic care management goals. Unsure of what steps to take to drive change, while taking on the increased risk of becoming an ACO the administrators partnered with CareThrough.
Shifting away from fee-for-service meant identifying value based care goals, while curtailing costs. However, with a large population of patients managing two or more chronic illnesses, administrators were confident the CMS reimbursement codes could support their efforts to become a thriving ACO.
“CareThrough was our trusted thought partner every step of the way. The leadership team helped us rethink our reimbursement model to better align staffing resources and enroll patients into our CCM program.”
When CMS linked Medicare reimbursement to Chronic Care Management, the rules were designed to address the needs of 65% of the Medicare population presenting two or more chronic conditions. The CDC reports that 81 million Americans will have two or more chronic illnesses by 2020. Often disease management is in the hands of the patients and their families.
From obesity and diabetes, to high blood pressure, the health system knew they could better serve their census with a strategic approach.
Navigators assisted care teams by first identifying eligible patients in the EMR, enrolling each patient, and then devising a follow-up plan to meet the minimum of 20 minutes of non-face-to face chronic care management services per calendar month.
When the site saw how well the program was growing and providers saw their patients improved health, they expanded the efforts. Today, as a full-fledged ACO meeting their Chronic Care management goals, care teams and administrators alike feel they are exceeding their mission to provide exceptional care to vulnerable populations.
“I’m definitely hopeful that we will continue to see progress in our CCM patients. The navigators who check in on CCM patients in between visits update the notes directly in the EMR so I am aware of any symptoms that have progressed, or need to be looked at further.”
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.