Work With ChronicCare
Patient Satisfaction​
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Without a coordinated care effort between provider and patient, patient experience and engagement stand to suffer, negatively impacting both patient and practice health.
Quality Scores​
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Value-based performance metrics can define your organization's financial validity. The value your patients receive from care coordination and value-based care programs determines your grade.
Reimbursements Decline​
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Poor value-based performance metrics can mean lower reimbursement rates, which make it more difficult to sustain your organization and create value for your patients.
Our ChronicCare Approach
Chronic Care Management
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Monthly care coordination services done outside of the regular physician office. It can include PCM, CCM, TCM, RPM & RTM.
Medication ​
Reconciliation
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Pharmacist review of patients' medications in order to reduce medication errors, and duplication.
Self-Care​
Management
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Our self-paced program educating patients to adopt healthy habits on nutrition, exercise, and lifestyle habits.
Our ChronicCare Solutions
Monthly, condition-specific care coordination & support for patients with a single high-risk chronic condition.
Using technologies to collect & transmit patient health data (BG, BP, HR, Weight) from home to providers for ongoing monitoring & support.
Monthly comprehensive, coordinated care & support for patients with two or more chronic conditions.
Track patient adherence and response to therapy using digital tools to support clinical decision-making and improve outcomes.
Supports patients transitioning from a hospital or facility to their home by ensuring timely follow-up & care coordination to prevent readmissions.
Seamless Integration
Our setup process is hassle-free. We integrate our HIPAA-compliant platform and services into your existing workflow. We identify eligible patients and obtain consent to enroll them in the program. Our virtual care team is made up of nurses, pharmacists, and care coordinators. We create care plans, deliver audit-grade billing reports, and provide Medicare chronic care service logs.
How it Works
STEP 1 - Identify patients​
Our team works with you to identify patients eligible (Medicare) for PCM, CCM and/or RPM services.
STEP 4 - Provide monthly care management​
Each month, our care team will call patients, update care plans, log time for billing, and proactively alert providers to potential issues which arise.
STEP 2 - Obtain consent to enroll patients​
Our team helps you obtain consent from patients. If patient hasn't been seen in 12 months, initiating visit is required prior to enrollment.
STEP 5 - Time tracking for accurate billing​
Our platform automatically logs time spent working on patient profile. Time tracking generates appropriate CPT code when threshold is reached.
STEP 3 - Create care plans ​
Virtual care team creates custom patient care plans using evidence-based guidelines. Physician can review and update or approve.
STEP 6 - Documentation for Billing​
We generate a report every month showing every CPT billable code for each each patient along with time spent.