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Chronic Care Management for Specialty Practices

What is Chronic Care Management?

Chronic Care Management (CCM) services are a CMS initiative for a targeted set of Medicare beneficiaries. Patients who qualify have at least two chronic conditions, each expected to last at least 12 months or until the patient’s death.

 

Pro Care Innovations offers practices CCM services via a monthly call service. Each patient receives 20 minutes of phone interaction from a PCI CCM nurse to discuss chronic care, diet, exercise, education, medication reconciliation, care plan, etc. All interactions are documented in their electronic medical record.

Isn't CCM generally offered by primary care providers?

Not necessarily. Patients can also receive CCM from their specialty providers. In many cases, this is a good option as patients with chronic conditions often have more interaction with their specialty provider for disease management making CCM a valuable tool in their care.

For example, a prostate cancer patient will most likely see their urologist more often than their primary care physician. By offering CCM to their qualified patients, the urology practice will ensure patients are receiving additional care in-between visits and can work with them to manage issues as they arise instead of waiting until their next appointment.

Pro Care Innovation is the CCM partner of many specialty medical practices supporting care for patients with multiple chronic conditions.

What patients are eligible?

PCI’s unique software identifies, filters, and analyzes these patients allowing each clinic to create a CCM-eligible patient list.

Examples of chronic conditions may include but are not limited to the following:
  • Alzheimer’s disease and related dementia

  • Arthritis (osteoarthritis and rheumatoid)

  • Asthma

  • Atrial fibrillation

  • Autism spectrum disorders

  • Benign prostatic hyperplasia

  • Cancers

  • Cardiovascular Disease

  • Chronic Obstructive Pulmonary Disease

  • Depression

  • Diabetes

  • Heart Failure

  • Hypertension

  • Infectious diseases such as HIV/AIDS

  • Obesity

  • Osteoporosis