Our Services

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Chronic Care Management (CCM) for patients with two or more chronic conditions is expected to last at least 12 months, which places patients at significant risk of death, acute exacerbation and or decompensation, or functional decline.

Principal Care Management (PCM) services for patients with a single chronic condition or with multiple chronic conditions but focused on a single high-risk condition. PCM services may be expected to last 3 months–1 year or until the patient’s death.

Pre-AWV visit telephone call to develop or update a personalized prevention plan and perform a health risk assessment. AWV is covered once every 12 months, and the patients pay nothing (if the provider participates in Medicare).

Get the patient’s written or verbal consent for CCM/PCM services before providing services. This helps ensure patients are engaged and aware of their cost-sharing responsibilities and prevents duplicate practitioner billing.

Provide 24-hour-a-day, 7-day-a-week (24/7) access to clinical staff, including providing patients or caregivers with a way to contact the assigned care coordinator to discuss urgent needs no matter the time of day or day of week.

Person-centered, electronic care plan based on physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and inventory of resources and supports for all health issues with a focus on managing chronic conditions.

Assess the patient’s medical, functional, and psychosocial needs. Ensure the patient receives timely recommended preventive services. Oversee the patient’s medication self-management and coordinate care with home- and community-based clinical service providers.

Manage care transitions between and among healthcare providers and settings, including referrals to other clinicians or follow-up after an emergency department visit or after discharges from hospitals, skilled nursing facilities, or other healthcare facilities.

Provide patients and caregivers enhanced opportunities to communicate with their care coordinators about their care by phone and through secure messaging, secure web, or other asynchronous non-face-to-face consultation methods (like email or secure electronic patient portal).

Record the patient’s demographics, problems, medications, and medication allergies using certified Electronic Health Record (EHR) technology. This means a practice must use a certified EHR system to participate in CCM/PCM programs.

Engage and educate the patient by developing and sharing the care plan with them (and any caregiver). Review the care plan periodically and revise as needed. Provide care that is tailored to the individual (also known as “person-centered” care).

For CCM/PCM services the billing practitioner doesn’t personally furnish, the clinical staff furnish them under direction of the billing practitioner on an incident to basis (as an integral part of services furnished by the billing practitioner).