Leveraging Third-Party Clinician-Led Care Teams to Enable More Effective and Profitable CCM, RPM, and TCM programs

by | Jan 15, 2021 | Blog

Treating medical conditions is not the same as caring for patients. This is an important concept and the foundation of managing a large patient population with chronic illnesses such as hypertension or coronary artery disease. Yet making the move from episodic care to chronic care management is difficult in our current healthcare environment. Time constraints are a primary contributor as the typical provider now spends two hours on administrative work for every one hour spent on direct patient care.[1]

But finding that time is essential. The CDC reports that failure to adequately manage chronic disease leads to increased hospitalizations, poorer outcomes, and higher levels of morbidity and mortality.[2] This is especially true for patients with complex cardiovascular disease and multiple comorbidities.

The good news is that recent changes by the CMS lets clinicians other than a cardiologist manage chronic care patients. New incentives for chronic care management (CCM), remote patient monitoring (RPM), and transitional care management (TCM) reduce the barriers of time constraints and lack of resources. The latest relaxation of telehealth restrictions provides even further benefits to these programs. And those benefits are substantial to the bottom line as well. A modeling study on the financial impact of CCM published by the Annals of Internal Medicine found that a typical practice could increase net annual revenue by more than $75,000 for each full-time provider and 12 hours of nursing service.[3] And that’s if just half of the patients who are eligible for CCM are enrolled.

One of the best ways to take advantage of all these programs have to offer is through clinician-led care management. The Cleveland Clinic serves as a prime example.[4] The organization implemented several outpatient chronic care clinics staffed by a nurse practitioner and a team of RNs. The RNs do the initial screening and evaluation before the patient sees the nurse practitioner. Debbi Fisher, COO of NavCare emphasizes the multi-faceted benefits of this approach. “Using a clinician-led team of professionals to help manage cardiac patients alleviates much of the burden on cardiologists and enables more proactive intervention,” Fisher said. “And this, in turn, can reduce ER visits, hospitalizations, and premature death.”

But not all cardiology practices have the necessary resources to open and staff multiple outpatient clinics. Fortunately, there is an alternative. Along with its other incentives for CCM, RPM, TCM, and telehealth, the CMS now allows third-party vendors to help manage these programs. This is a great option that can bring faster ROI to the practice. When evaluating a vendor to help with your CCM, RPM, TCM, and telehealth initiatives, there are several things to consider. Following are six items to look for.

Rapid enrollment. No matter how many patients you decide to enroll in your CCM program, your vendor should be able to get them all enrolled quickly. Anything longer than 30 days is too long. You want the transition to be as smooth and easy for patients as possible. The goal is to assure them that this is to their benefit, not that it will be difficult for them to participate.

Care delivered by licensed clinicians. One of the primary goals of CCM is to enable quick interventions for cardiac patients experiencing problematic trends or quickly escalating events such as heart attack or stroke. Even the best-trained call center rep can’t screen or triage a patient as effectively as LPNs and RNs. This is a critical must-have for your program. Everyone who engages with your patients should act as a part of your own clinical care team. Only licensed clinicians can do this.

Full transparency. All patient interactions should be fully documented, and regular reports should be made available through online dashboards. This should include analytics such as cardiologist performance within the program. Your vendor should also provide all relevant coding for you to use in billing and claim submissions.

Plug and play. Patients don’t always have access to PCs, smartphones, or tablets—especially senior patients. And their comfort and knowledge of technology can make the use of such devices challenging. Your vendor should provide remote devices that are easy for patients to use. For example, a hub or tablet that sits on the side table and has a nurse call-out button is a good option that doesn’t require pairing or complex connectivity. Better yet, a dedicated tablet gives patients visual access to their care team, along with other interactive options like telehealth appointments.

Remote monitoring devices. Many remote devices like blood pressure cuffs and pulse oximeters are easy enough for patients to use. But there are other devices that automatically report issues to the care team in real-time. For example, fall-detector pendants and personal emergency response devices can immediately signal when help is needed. This can be critical for post-op heart surgery patients who have transitioned to recovery at home.

A more effective approach

Using a third-party as your clinician-led CCM program provides all the benefits of an internal program while reducing the burden on cardiologists. Leveraging a partner in this way can bring faster ROI, along with improved outcomes and reduced costs. It also enhances the patient experience, which can improve utilization and patient satisfaction rates.


[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5593724/

[2] https://www.cdc.gov/mmwr/volumes/66/wr/mm6645a2.htm

[3] https://www.acpjournals.org/doi/10.7326/M14-2677

[4] https://www.advisory.com/daily-briefing/2017/10/24/chronic-care

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