Enhancing Healthcare Outcomes with CCM: From Patient Screenings to Addressing SDOH

Care gaps are very disastrous to patients’ health. When patients fail to be recommended with the necessary assessments, vaccinations, or screenings, they are at risk of getting an illness from a preventable disease or seeing their chronic conditions deteriorate and their quality of life is affected. 

Those practices that address care gaps in healthcare delivery benefit from significant gains in the form of financial returns from CMS, support in meeting compliance and reporting mandates, and performance expectations from health plan partners while maintaining sound contractual relationships.

However, if healthcare practices are not very good at addressing the gaps in care, they score lower in quality programs and get lower reimbursements for their value-based care programs. Even if your practice is very conscientious about recognizing that there are deficiencies in care, you may not have the manpower or the time.

Supporting Patients with Chronic Care Management

Under Chronic Care Management, Medicare patients with not less than two chronic conditions receive preventive care on a monthly basis. Patients will have monthly visits with a care coordinator and virtual support through a phone and text line available at any time after enrollment.

The following are some ways in which their care coordinator can assist them:

• Develop care plans and goals
• Plan or reschedule appointments
• Refill the prescriptions
• Check their blood pressure or blood sugar levels
• And find resources in the community

They may also ask their care coordinator to discuss other elements of care that are often missing for older patients, including breast, colon, or cervical cancer, Hb A1c level, or vaccination.

Bridging Care Gaps with Coordinators

If care coordinators find that there is a gap in the record of a particular patient, they can ask the patient if he or she would like to close that gap. The care coordinator can then do the assessment; indicate the patient has done the screening, vaccination, or assessment elsewhere; indicate the patient has refused the service; or refer the patient back to the practice for face-to-face service.

Impact of Chronic Care Management on Bridging Healthcare Gaps

Providers and care coordinators also fill several deficits in care by often probing in on patients, conducting assessments, compiling the patient’s files from different centers, and re-directing them back to the practice.

In the CCM program, 100% of engaged patients receive clinical assessments like: 

• Condition Awareness Screening
• Activities of Daily Living Screening

In case the assessment shows that the patient needs assistance, their care coordinator can take them back to their provider. Additionally, care coordinators can assist patients in locating nearby resources such as support groups, medical equipment agencies, medication delivery services, and transportation.

Perhaps, one of the most critical aspects is the possibility to recognize Social Determinants of Health needs as fast as possible. Essentials such as safe shelter, transportation, and good nutrition are also known to have a direct influence on health. 

SDOH can be screened via phone, and care coordinators can do this during monthly follow-up calls. If screening shows that the patient requires additional assistance, the care coordinator can refer them to food banks, housing authorities, utility companies; senior centers, and other resources within the community.

The Importance of Addressing Care Gaps

Chronic Care Management can help patients prevent and manage illness by identifying and addressing gaps in care, leading to better long-term health outcomes. At the same time, practices could see improvements in their value-based care and quality performance. 

Chronic Care Management gives practices multiple opportunities to address care gaps with Medicare patients, up to twelve times a year. Care coordinators build relationships with patients while ensuring they have access to needed screenings, vaccinations, SDOH resources, and assessments. 

Chronic Care Management thus plays an important role in filling those gaps to improve patients’ health and keep off illnesses. Practices could also benefit from the improvements in both value-based care and quality performance at the same time. 

Chronic Care Management provides practices with twelve opportunities per year to address Medicare beneficiaries’ care deficiencies. Care coordinators nurture patient relationships while helping patients access a particular screening, vaccination, SDOH, or assessment. 

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