Care Coordination Services

Twenty (20) or more minutes of CCM/PCM clinical staff time may be furnished in a calendar month directed by a physician or qualified health provider (i.e., MD, DO, NP, PA, CNM). State law, licensure, and scope of practice definitions must be considered for non-primary care service providers

Care Coordination Services

Electronic Health Records (EHR)

Certified Electronic Health Records (EHRs) must be used to record certain patient data, including the patient’s demographics, medical problems, medications, and medication allergies. EHR can help to identify high-risk and at-risk patients for participation in the CCM program and help to effectively manage chronic conditions and population health.

Electronic Health Records (EHR)

24/7 Access to Care Team

Access to physicians or other qualified health care professionals or clinical staff including providing patients/caregivers with a means to contact health care professionals in the practice to address urgent needs regardless of the time of day or day of week, and continuity of care with a

designated member of the care team with whom the patient can schedule successive routine appointments

Comprehensive Care Plan

Person-centered, electronic care plan based on physical, mental, cognitive, psychosocial, functional, and 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

✦ Make electronic care plan available and shared promptly both within and outside the billing practice with individuals involved in patient’s care

Our care coordination services ensure seamless communication between different healthcare providers. We facilitate sharing of patient health information, thus ensuring comprehensive care. We work with specialists, primary care doctors, and other healthcare professionals to ensure the patient's health is managed effectively.

Comprehensive Care Plan

Problem list

Expected outcome and prognosis.

Measurable treatment goals

Cognitive and functional assessment

Symptom management

Planned interventions.

Medication management

Environmental evaluation

Caregiver assessment

Interaction and coordination with outside resources, practitioners, and providers

Requirements for periodic review

When applicable, revision of the care plan

Continuity of Care

Structured recording of patient health information using Certified EHR Technology and includes demographics, problems, medications, and medication allergies that inform the care plan, care coordination, and ongoing clinical care.