Chronic care management (CCM) is a critical component of primary care that contributes to better outcomes and higher satisfaction for patients and providers. The Centers for Medicare & Medicaid Services (CMS) recognizes CCM takes time and effort. CMS established separate payment under billing codes for the additional time and resources you spend to provide the between-appointment help many of your Medicare and dual-eligible (Medicare and Medicaid) patients need to stay on track with their treatments and care plans. CCM payments can be made for services furnished to patients

• with two or more chronic conditions and who
• are at significant risk of death,
• have acute exacerbation/decompensation or
• are in functional decline.

 
CMS data show two-thirds of people with Medicare have two or more chronic conditions, which means many of your patients may benefit from a CCM program, including the help provided between visits. CCM can help deliver the coordinated care your patients need and deserve.
 
Mountain-Pacific Quality Health invites you to participate in a CCM program project. Under this project, Mountain-Pacific will work with eligible practices to:

1. Conduct a workflow assessment in primary care practice;
2. Evaluate existing tools and identify supplemental resources;
3. Provide initial orientation of staff who will be care coordinators as well as staff in support roles;
4. Provide a continuing education network for care coordinators and support staff to share best practices, provide resources and ongoing peer support for medication safety and adherence and care coordination skills; and
5. Provide a supportive environment for continued learning.