Beyond chronic care management and remote patient monitoring, CCI's registered nurses can deliver these additional Medicare-covered services on behalf of your organization.
Advanced Primary Care Management
Ongoing management of a patient's primary care, paid as a set monthly amount per enrolled patient. The amount depends on how many chronic conditions the patient has and whether they are a Qualified Medicare Beneficiary.
There is no minimum amount of time to record each month. Instead the organization must be able to provide thirteen defined elements, including patient consent, 24-hour access for urgent needs, a named care team member, an electronic care plan, follow-up within seven days of a discharge, and risk stratification across the patient population.
Only one practitioner can bill it for a patient in a given month, and it cannot be billed alongside chronic care management or transitional care management for that patient that month.
CCI's nurses deliver the ongoing care management work.
Annual Wellness Visits
A yearly visit that produces a written prevention plan for the patient — a health risk assessment, a review of their history and medications, cognitive and depression screening, and a schedule of the screenings that are due.
It is a benefit most Medicare patients are entitled to and many never use. For your organization it is also the visit that surfaces which patients need closer management.
CCI's nurses carry out the assessment and build the prevention plan.
Transitional Care Management
Management of a patient's first thirty days after they leave hospital or a skilled nursing facility. Contact within two business days of discharge, a medication reconciliation, and coordination of scheduling a face-to-face provider visit within a week or two depending on how complex the case is.
This is the window when patient readmissions are most likely. This critical time is often overlooked after discharge.
CCI's nurses make the early contact, reconcile the medications and coordinate the follow-up.
Risk and Screening Assessments
Standardized questionnaires completed about a patient, or about the family member caring for them, then scored and documented.
A scored questionnaire produces a documented result where there was previously only a clinical impression.
These assessments together with provider impressions support better patient outcomes.
Risk and screening assessments are separately billable after being administered and documented by CCI registered nurses.
