3 essential ingredients for an effective chronic care management program

Approximately one in four adults, including 70% of Medicare beneficiaries, live with at least two chronic conditions, qualifying them for chronic care management (CCM). At Engooden, we talk about how extending quality care to chronically ill patients outside the clinic is as important as the care provided inside it. Providers understand that CCM is crucial for closing care gaps and achieving better health outcomes, but building an effective program can be daunting if you’re unsure where to start.

To help point you in the right direction, here are the three things you need to build a successful CCM program at your practice.

A qualified care team
If you don’t have the appropriate resources to staff a CCM program, the effort will be doomed before it gets off the ground. Many Engooden customers have struggled to scale CCM because they lack the clinical staff to reach patients adequately. These chronic disease programs introduce a new set of responsibilities, which can quickly become unsustainable for personnel already committed to other operational roles.

At the same time, a CCM program must deliver return-on-investment to remain viable. Finding resources is the first great challenge: building a CCM team that can successfully identify and enroll patients, manage new workstreams, and conduct ongoing patient outreach in a scalable, sustainable way. Our teams are certified medical assistants, who connect with patients one-on-one.

Tech-enhanced EHR analysis and integration
Chronic care management requires a multi-dimensional approach that couples technology with personalized outreach. Once your team is in place, they should begin finding and onboarding eligible patients to enroll in your CCM initiative. To identify the most patients, facilitate enrollment, and gain continual access to the most recent patient information, you need advanced technology that can analyze EHR records.

Relying on your CCM staff to manually review EHRs can be an arduously slow process. Fortunately, equipping your staff with tech solutions that automate the process takes out the leg work and frees up resources. Engooden’s secure technology, which is HITRUST certified, integrates with EHRs to continuously find updates for patients in the program and to identify additional patients who qualify for chronic disease management services.

For starters, use your tech-enhanced EHRs to identify patients with the most common chronic conditions, such as hypertension, diabetes, or COPD. You can enroll interested patients and begin surfacing care gaps during their ongoing treatment.

It may sound trite, but the most successful relationships between providers and patients are built upon trust. Patients that feel they are receiving personalized care are more likely to follow through and complete treatment. Whether calling to confirm a patient picked up their prescription, scheduling transportation to an appointment with a specialist, or just calling to check in, showing a genuine interest in patient care is crucial to a successful CCM program.

At Engooden, our care navigators are real-life superheroes working to protect our patients daily. We don’t just find patients and enroll them; we build relationships, advocate for their health, and find solutions to the real hurdles impacting their health. No problem is too small or large, be it compiling dietary recommendations, pursuing emergency interventions, or asking about a patient’s day. We foster trust and a deep, emotional connection that allows us to uncover care gaps and insights that can be easily overlooked during a short office visit.

CCM with Engooden
Chronic care management is an excellent opportunity to increase revenue streams while making a tangible improvement in the lives of your patients. By partnering with Engooden, you don’t need to worry about finding care navigator talent, carrying out human resource processes, onboarding, training, and other related costs and efforts. Our tech-enabled services allow for smooth scaling without added training, hiring, upfront costs, or overhead.

Your practice and patients are in good hands with our team of clinically trained and skilled care navigators. Our track record speaks for itself, with 84% of all eligible patients reached and 88% patient retention rate. Our 93% monthly connection rate ensures you and your staff maintain consistent insight into the lives and health of your patients.

With 96% patient satisfaction, our workflows are proven. Our technology delivers compliance and audit tracking to sync with Medicare, automated billing, and seamless integration with leading physician EHRs to ensure you retain up-to-date access to all clinically relevant information. We have established a new standard of care for patients with chronic conditions with consistent outreach, a human touch, and a custom care plan.

A solid CCM program is the foundation for improving patient health and satisfaction, reducing cost, and understanding patients’ needs; which sets providers up for success in other value-based programs. If you’re curious about chronic care management, contact Engooden to learn how you can build a scalable program.