Central Florida
Chronic Care Management Group

Chronic Care Management Services

 

Initiating Visit and Informed Consent

• Assistance with scheduling initiating visit (face-to-face E/M visit, AWV, or IPPE) for new patients or patients who the billing practitioner hasn’t seen within 1 year before CCM services start, as well as obtaining and documenting informed consent.

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Structured Recording of Patient Health Information Using Certified EHR Technology

• Recording the patient’s demographics, problems, medications, and medication allergies using certified EHR technology. A full EHR list of problems, medications, and medication allergies must inform the care plan, care coordination, and ongoing clinical care.

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24/7 Access & Continuity of Care

• Provide 24/7 access to physicians or other qualified practitioners or clinical staff, including providing patients or caregivers with a way to contact health care practitioners in the practice to discuss urgent needs no matter the time of day or day of week.

• Provide continuity of care with a designated practitioner or member of the care team with whom the patient can get successive routine appointments.

 

Comprehensive Care Management

• Assess the patient’s medical, functional, and psychosocial needs.

• Make sure the patient receives timely recommended preventive services.

• Oversee the patient’s medication self-management.

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Comprehensive Care Plan

• Create, revise, and or monitor (per code descriptors) a person-centered, electronic care plan based on physical, mental, cognitive, psychosocial, functional, environmental (re)assessment, and inventory of resources and supports.

• Comprehensive care plan for all health issues with focus on managing chronic conditions.

• Provide patients and or caregivers with copy of the care plan.

• Electronically capture care plan information and make it available promptly both within and outside billing practice with individuals involved in the patient’s care, as appropriate.

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Managed Care Transitions

• Manage care transitions between and among health care 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 health
  care facilities.

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Home- and Community-Based Care Coordination

• Provide patients and caregivers enhanced opportunities to communicate with their practitioners 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).