Value-based care is all about what happens between doctor visits. And Chronic Care Management may not be enough.

In 2014, Medicare acknowledged the benefits of closer contact with patients who have chronic conditions. Chronic Care Management became a reimbursable service, and usage of the CCM codes increased every year since.

But with two-thirds of all Medicare patients diagnosed with multiple chronic conditions, success in value-based care may require a more high-touch and targeted approach than your standard CCM program.

You say, “Ok, but I bring in revenue from CCM.”

True, and CMS recently increased rates. But this is another case where value-based care requires rethinking what works under straight fee-for-service.

As part of a full-risk Accountable Care Organization or Medicare Advantage program, patients receive a benchmark based on their medical history. The difference between what Medicare expected to spend on a patient’s care and what’s actually spent becomes your shared savings rate. Each claim submitted to Medicare counts toward a patient’s benchmark, and therefore reduces available shared savings.

It’s worth making sure all care brings value to the patient. Is simply checking the CCM box enough?

Focus care. Get results.

Not every patient with a chronic condition needs additional management. But many do.

Social determinants of health can be just as predictive about who may be heading toward an unnecessary hospitalization. But your EHR likely doesn’t give you much insight into a patient’s housing situation or access to transportation.

Your practice needs to know how to spend its limited time, especially if you’re working in full-risk value-based care. Our population health tool, Clarity, helps you identify patients who need more extra attention. And when you partner with Wellvana, you can summon our Care Team to support those patients between visits.

Consider the cost.

CCM isn’t free to patients. Depending on their Medicare supplemental plan, they likely have some kind of out-of-pocket cost. Even if small, your patients who need the most help are often the patients who can least afford it. The cost can inhibit engagement and adherence.

Our approach to care management is different. Wellvana-managed patients can receive ongoing support from a licensed team of clinicians without ever seeing a bill.

Finding Lost Patients

Some patients need additional support precisely because they haven’t been able to come into an office. But Medicare requires a face-to-face visit before initiating CCM. Patients need something that can start simply with a phone call.

Compassion and empathy take time.

CCM can be as little as 20 minutes a month. It’s hard to establish trust when the clock is ticking.

But before you can get to medication adherence or what’s really bothering a patient, you might also need to hear the latest about their family or the social determinants of health struggles they may have with food or transportation. That takes time your staff may not have.

Wellvana's Foundational Care Management goes beyond CCM.

As an extension of ACO member practices, Wellvana offers Foundational Care Management as a level up to traditional Chronic Care Management. Wellvana’s dedicated team of nurses and care coordinators work to identify and address barriers impacting a patient's condition or their ability to manage their condition appropriately. This can involve everything from working the phones for hours just to sort out a prescription mix-up to making sure a wheelchair gets delivered so your patient can come in for a follow-up.

The only goal is keeping the patient as healthy as possible, and it rarely takes a simple 20-minute call.

The stories speak for themselves.

A patient in Arizona was discharged from the hospital, triggering a call from Wellvana to make sure he went to see his primary care physician for a follow up. The patient wasn't interested.

During his first call with Care Coordinator Michelle Wadley, LPN, the patient said he didn't have transportation. Michelle offered to find him a ride — as she had for many other patients but he declined. Eventually, he declared he was done with doctors.

With a few more phone calls, Michelle realized the patient was in a dark place following the death of his wife. Michelle eventually convinced this patient he owed it to himself and his late wife to see his physician following his hospital stay.

He finally listened. And she scheduled an appointment on the spot.

His PCP wasn't thrilled with how long it had been since the last checkup, but the patient left happy, with home health assistance and a ride scheduled for his next appointment.

Foundational Care gets results.

Through creativity, clinical expertise and regular communication, Wellvana is helping practices reduce hospitalizations by more than 22% and decreasing medical spend by 16%. By comparison, CCM’s impact is in the single digits.

Our team is your team.

For practices who partner with Wellvana, our Foundational Care team acts on your behalf. They’re not on your payroll, but they truly care and support your patients like a member of the practice. Our nurses are making sure your care plans are carried out and supporting patients between visits so they don’t slip through the cracks.