In parts one & two of our Chronic Care Management (CCM) series, we explored how qualified patients can benefit from CCM. And how South Carolina & Georgia House Calls utilizes in-home primary care providers, technology, and multiple in-house specialists to provide CCM service throughout the region. In our final installment, part three summarizes the components making up the CCM program and how patients qualify and enroll in CCM.
• Enrollment:
CCM services start with a face-to-face visit that may be part of an annual wellness visit or initial preventive exam. A patient to qualify will have two or more chronic conditions. The provider on this initial assessment will inform the patient about potential patient cost-sharing responsibilities and that patients have the right to cancel their enrollment at any time. To enroll, a patient must give verbal or written consent, and that decision is included in their medical record.
• EHR:
The electronic health record is instrumental within the CCM program to ensure all care, test results, monitoring, and labs are documented in real-time and available to internal and external medical personnel involved in the individual's patient care.
• Access:
Because of the chronic nature of the illnesses, it is a requirement that patients enrolled in the CCM have an enhanced level of access to medical personnel. The SC & GA HC call center provides 24-7 coverage with medical professionals available to discuss any urgent needs of the patient and caregiver.
• Care Management:
The comprehensive care management provided through CCM includes a patient's medical, functional, and psychosocial needs. The team also oversees medication self-management and provides timely preventive services regularly.
• Care Plan
The medical team is responsible for developing a comprehensive care plan for all known healthcare issues, particularly managing the patients' chronic conditions. Copies of the care plan are provided to the patient and their primary caregiver.
• Transitions:
In addition to providing consistent patient care, the CCM team is tasked with managing transitions among health care providers, including referrals to other clinicians. The care team follows up with CCM patients after ER visits, discharges from a hospital, skilled nursing, or any other facility.
• Coordination:
The care team coordinates care with in-home providers and community-based practitioners to provide a seamless level of care for the patient.
• Communications:
The CCM patient enrolled with SC & GA HC has enhanced opportunities to communicate with their practitioner through the call center or patient portal. The patient portal provides a path for communication and is also a source of information, including the patient's electronic health records, lab, test results, and billing information.
SC House Calls & GA House Calls is a network of over 250 medical professionals providing In-home medical house calls and Telehealth visits to Private Residences, Assisted Living Communities, and Skilled Nursing Facilities. SC House Calls serves all 46 Counties of South Carolina. New patient registration, appointments, and 24-7 access to medical professionals are available through its Center for Telehealth @ 800-491-0909
