CHRONIC CARE MANAGEMENT TOOL KIT What Practices Need to Do 2025

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A care plan should include: A comprehensive list of health conditions. The expected prognosis and outcomes of these conditions. Treatment goals that are measurable, with a place to record progress. An assessment of functional and cognitive abilities of the patient. A strategy for managing chronic symptoms.
Chronic Care Management: How to Start Your Program Step 1: Develop a Plan and Form Your Care Team. The first step to take is to develop a plan for your office. Step 2: Identify and Recruit Eligible Patients. Step 3: Enroll Your Patients. Step 4: Deliver CCM and Engage Patients. Step 5: Coding, Billing, and Reimbursement.
The following should be documented in the EHR: Patient consent, Comprehensive care plan, including, but not limited to, a problem list, measurable treatment goals, planned interventions, medication management, and interaction and coordination with outside resources and practitioners and providers, and.
Knowing which patients qualify, the required services, and the role your practices staff will play are all important for success. The first step is to determine who will provide and bill for these services in your practice.
Review patient eligibility Before implementing a CCM program, you must first review whether or not you have enough eligible patients to justify launching the initiative. CCM is available to all Medicare Part B recipients who have two or more qualifying chronic conditions.
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10 Steps to Start a Chronic Care Management Program Evaluate the requirements for a CCM program. Explore the resources, infrastructures, and workflows involved in CCM operations. Review patient eligibility. Educate and enroll patients. Develop continuous patient engagement plans. Plan out the patients care journey.
Requirements: Two or more chronic conditions expected to last at least 12 months (or until the death of the patient) Patient consent (verbal or signed) Personalized care plan in a certified EHR and a copy provided to patient.

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