Need to network with Care Coordinators who deal with Medicare patients in private practice

asabau87 · Apr 14, 2015

It is a very demanding job. I am the only Care Coordinator in a practice of 16 providers and 6 NP's with 7000 Medicare patients that have Chronic Diseases. I have set up their Transitional Care Program and its running fairly smooth with the process I have in place. Now my next bog task is to establish the CCM program which is slightly more complicated. On top of that I also try to keep trying of their Home Health patient and work with billing to bill for those Care Plan Oversights. I love the job, just sometimes I get slightly overwhelmed and I am alone at this point. They are looking to get me 2 people under me to help. In the mean time I need to set up the work flow for Chronic Care Management and I would love to hear how other practices do it.

2Bretired · Apr 17, 2015

asabau87, you have taken on a tough job to handle alone! Identifying and stratifying the patients is important. Right now our program ranks them by acuity and the 5 chronic diseases, takes into account hospital and ER visits as well as $$ for care. 5 is the highest and they of course are the hardest to improve, we focus on anyone 2.5 and above on our lists. Because we are a Health Insurance we have great IS support to pull data from our claims. We also work with Gaps in care, if members/patients have not had A1c, diabetic foot exams, BP checks, colonoscopies- we engage them to have these done, that is part of being an ACO clinic. After you identify the patients you need to work with we "target them" in our program and start on the Assessment. It is absolutely crucial to have a good working computer program that interfaces with a medical record so you have access to information. You are lucky that you are in the office with the providers, that makes it so much easier to engage the patients. Good luck with your efforts, it is very rewarding but also very draining! You will need some help for sure!!