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Chronic Care Management (CCM) helps practices provide ongoing care and coordination for patients living with multiple chronic conditions—well beyond the traditional office visit.
At The Rize Group, we help practices build and operate comprehensive CCM programs designed to keep patients connected to their care team, strengthen care coordination and support better management of chronic conditions.
From patient identification and enrollment through monthly care management, comprehensive care plans, documentation and ongoing patient engagement, we provide the operational support necessary to make CCM work inside your practice.
CCM is designed for patients with two or more qualifying chronic conditions expected to last at least 12 months or until the patient's death and that place the patient at significant risk of deterioration, exacerbation or functional decline.
But successful Chronic Care Management is about much more than documenting time.
It is about maintaining an ongoing relationship with the patient, understanding what is happening between office visits and helping coordinate the many components of their care.
That may include medications, specialists, appointments, treatment goals, preventive care, transitions between healthcare settings and other medical or psychosocial needs.
Operating CCM successfully across hundreds or thousands of patients requires people, processes, technology and consistent execution.
The Rize Group provides the operational infrastructure necessary to help practices implement, manage and scale their Chronic Care Management programs.
Patient Population Identification
Identify patients within your existing population who may meet the clinical requirements for CCM.
Patient Education & Enrollment
Educate patients about the program, obtain appropriate consent and establish them within the CCM workflow.
Comprehensive Care Plans
Develop, maintain and update patient-centered care plans reflecting conditions, medications, treatment goals and care needs.
Monthly Care Management
Provide structured clinical care-management activities based on the patient's conditions, needs and established care plan.
Patient Engagement & Outreach
Maintain ongoing communication with patients to identify needs, reinforce treatment plans and keep them connected to their care team.
Medication Management
Support medication reconciliation, adherence, education and identification of medication-related concerns.
Care Coordination
Coordinate with specialists, pharmacies, hospitals, caregivers and other members of the patient's healthcare team.
Transitions of Care Support
Assist with appropriate follow-up and coordination when patients move between hospitals, emergency departments, rehabilitation facilities and other healthcare settings.
Preventive Care & Care Gaps
Identify opportunities for preventive services, follow-up care and other quality initiatives.
EMR-Based Documentation
Work within your existing electronic medical record environment so care-management activities, communication and care plans remain connected to the patient's chart.
Program Monitoring & Performance Management
Track patient engagement, care-management activity, workflow performance and program opportunities.
A patient's chronic conditions rarely exist independently of one another.
Managing diabetes may involve medications, laboratory testing, nutrition, specialists and preventive care.
Managing hypertension may require monitoring blood pressure, medication adherence and follow-up with the provider.
A strong CCM program helps connect those pieces.
Our team works within the infrastructure of your practice so providers maintain visibility into what is happening with their patients between visits.
Evaluate the patient population and identify potential CCM candidates.
Explain the program, obtain appropriate consent and enroll the patient.
Review the patient's chronic conditions, medications, treatment goals and care needs and establish the comprehensive care plan.
Perform ongoing care-management activities and communicate with the patient based on their individual needs.
Coordinate necessary care and document relevant activities within the patient's medical record.
Monitor engagement, clinical opportunities and program performance to continuously strengthen the program.
Launching CCM is relatively simple.
Operating CCM consistently across an entire patient population is where the challenge begins.
Patients have different conditions, medications, providers, specialists, appointments and barriers to care. Effective care management requires a team and workflow capable of identifying those needs and acting on them month after month.
The Rize Group helps provide that infrastructure.
Your providers remain responsible for the patient's medical care.
We help extend the reach of your practice between office visits.
Chronic Care Management creates an opportunity to strengthen the connection between patients and their healthcare team while helping practices take a more proactive approach to managing chronic disease.
The value of CCM is not simply the monthly service.
It is creating a system that helps your practice stay connected to the patients who need you most.
Whether you're evaluating Chronic Care Management for the first time, preparing to launch or looking to improve an existing program, The Rize Group can help build the people, processes and operational infrastructure necessary to move forward.
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