There is a widespread realization that health care in the U.S. remains fragmented and lacks longitudinal coordination of care. As a result, health care costs are higher, and outcomes worsen. The Centers for Medicare and Medicaid has addressed this in a limited fashion by implementing CPT codes for chronic care management (CCM). While many practices have instituted Centers of Excellence to coordinate care for specific patient populations, a proper CCM program involves clinical and operational infrastructure, a technology platform, compliance processes and revenue cycle management. While various companies offer these services, adopting and managing a CCM program that integrates into the practice workflow and provides actual value to the patient involves much more than signing a contract.
To enroll patients in CCM, they must have two or more chronic conditions expected to last 12 months or more that put them at risk of hospitalization, death or functional decline. In gastroenterology, the most common conditions that meet these criteria are inflammatory bowel disease (IBD) and chronic liver disease. Therefore, a practice must define the medical conditions they will manage and the patients who would benefit from that enhanced, non-face-to-face care. Care coordinators contact a patient and generate a care plan, which the physician will review regularly. A trusted care manager can be a trained medical assistant, an advanced practice provider or another health professional under the supervision of the attending physician. These individuals may be employees of the practice or outsourced to a CCM company. In either model, appropriate training and supervision are the keys to a quality program.
Finally, the most vital segment of this coordinated care model is integrating the output of the care coordinators into the physician's daily workflow. Knowing that a patient with IBD reported flare symptoms to the care coordinator, but the physician did not see that interaction for two weeks is of little use. A collaborative working relationship between all members of the care team is vital, and bidirectional communication between the patient and the care coordinator must be seamless and reliable. The goal of the program is to improve outcomes. For IBD, that means avoiding unplanned care events like emergency room visits and unnecessary radiology studies, surgeries and courses of steroids. For chronic liver disease, it is monitoring diet, weight and clinical status to prevent or delay disease progression. For any disease process, it is improving quality of life through enhanced care coordination.
Paul Berggreen, MD
Chief Strategy Officer
GI Alliance