Blueprint for Implementing and Capturing Revenue for Chronic Care Management (Spotlight Poster)

Chronic care management (CCM) services are a vital aspect of health care. They are critical to improving the health and wellness of individuals with chronic conditions while reducing the cost of healthcare. Nurses and interdisciplinary care team members are pivotal in providing services like developing care plans, coordinating care, and educating patients. These services are typically provided non-face-to-face and are often not captured as billable charges. Nurse leaders partnered with a team of interdisciplinary department leaders to develop a blueprint for ambulatory practices to implement a system to capture the time spent by nurses, providers, and clinical staff to charge for CCM services to improve patients' health.
Centers for Medicare and Medicaid Services (CMS) added CCM billing codes in 2015 and since has expanded these codes to encourage healthcare providers to develop care delivery models aimed at improving the lives of patients with chronic conditions such as diabetes, congestive heart failure, hypertension, chronic pain, and behavioral health diagnoses. Despite the availability of these new billing codes, the guidelines and requirements can feel burdensome to busy clinicians. They can be a barrier to implementation, particularly in large academic medical centers, where implementing new models of care can be challenging.
In January 2023, a working group was formed, including ambulatory care nursing leadership, nurse informaticists, hospital compliance, finance, revenue cycle, and project management, to analyze the opportunity for implementing CCM services and billing across ambulatory care practices. After researching and analyzing the potential return on investment, such as patient outcomes and experience, nurse satisfaction, and financial impact, the team developed the initial workflows, tip sheets, patient information, and reports to implement CCM.
A senior health primary care practice was identified as the initial pilot practice to determine the feasibility of scaling CCM across ambulatory care practices. Front-line nurses and providers were engaged in the pilot's logistics. Empowering their voices, they informed CCM resources and workflows, which led to the development of a comprehensive toolkit we uploaded to our ambulatory blueprint page, an internal site for easy access. All practices will use this blueprint page to adopt CCM.
To prepare for the pilot go-live, the implementation team conducted an in-person shadow day to assess and review the practice's workflows and identify any potential barriers. Education and training were provided. Weekly meetings were scheduled to evaluate progress, identify barriers, and address questions and concerns.
In January 2024, the senior health practice began enrolling qualified patients into CCM and time tracking for services provided. By June 2024, the practice enrolled 20% of patients qualifying for CCM, and the practice is exploring evidence-based approaches to improve patient outcomes.
The complexity of CCM can be a barrier to optimizing billing. Using the CCM toolkit, we have implemented CCM billing in several ambulatory care practices. Billing and revenue are meeting expectations, and we are continuously evaluating the full return on investment. The success of our first CCM pilot can be attributed to the leadership, collaboration, engagement, and support of our interdisciplinary team and the creation of the ambulatory blueprint for CCM.