care management services

The term "care management" refers to a broad range of services and initiatives that support patients with long-term or complex medical illnesses in taking control of their health. The primary objective of care management is to increase patient health. Along the way, the strategy hopes to increase patient participation, decrease hospital visits, and enhance care coordination.

As a major practice-based technique for managing the health of people with complicated or chronic medical disorders, care management has evolved. Care management programmes can enhance the standard of care and assist patients in achieving and maintaining better health by integrating systems, science, information technology, and encouragement.

Why to opt for care management?

  • Better clinical results.
  • Decreased reliance on expensive acute care services.
  • More appointments for primary and/or preventative care.
  • Fewer examinations and procedures that are repeated.
  • Increased patient contentment.

Patient Eligibility

Chronic care management

  • >=2 chronic conditions lasting for >12 months
  • Example:
    • Arthritis
    • Asthma
    • Atrial fibrillation
    • Cancer
    • Cardiovascular disease
    • COPD
    • Depression
    • DM
    • HTN
    • HIV
    • Alzheimer’s disease and related dementia

Principal care management

  • 1 complex chronic condition expected to last at least 3 months
  • Example:
    • The condition that place patient at significant risk of hospitalization
    • Acute exacerbation
    • Decompensation
    • Functional decline
    • Death

Remote patient monitoring

  • High BP
  • DM
  • Weight loss or gain
  • Heart conditions
  • COPD
  • Sleep apnea
  • Asthma
  • Example:
    • Weight scales
    • Pulse oximeters
    • Blood glucose meters
    • Blood pressure monitors

Practice Requirements

Chronic care management

  • Continuous patient relationship with chosen care team member
  • Supporting patients with chronic diseases in achieving health goals
  • 24/7 patient access to care and health information.
  • Patient receiving preventive care.
  • Patient and caregiver engagement.
  • Prompt sharing and using patient health information.

Principal care management

  • Continuous patient relationship with chosen care team member
  • Supporting patients with chronic diseases in achieving health goals
  • 24/7 patient access to care and health information.
  • Patient and caregiver engagement.
  • Prompt sharing and using patient health information.

Remote patient monitoring

  • Continuous patient relationship with chosen care team member
  • Prompt documentation and securing the data received from patient in EHR.
  • Support should be available when the received data is alarming.

Frequency & Modeof Communication

Chronic care management

  • Minimum 20 mins/month via call, text, secure email or EHR.
  • Billed once/month if required with add-on code.

Principal care management

  • Minimum 30 mins/month via call, text, secure email or EHR.
  • Billed once/month if required with add-on code.

Remote patient monitoring

  • Minimum 16 readings/month and/or 20 mins/month for care management coordination.
  • Billed once/month if required with add-on code.

Eligible Professionals

Chronic care management

  • Physician
  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Nurse Midwives

Principal care management

  • Physician
  • Physician Assistants
  • Nurse Practitioners
  • Clinical Nurse Specialists
  • Certified Nurse Midwives

Remote patient monitoring

  • Physician
  • Physician Assistants
  • Nurse Practitioners