Chronic Care Management and Remote Patient Monitoring Explained

What is Chronic Care Management?

Traditionally, care for patients living with long-term health conditions relied heavily on in-person visits. The approach is inadequate because ensuring superior outcomes for patients with chronic conditions requires ongoing engagement and support beyond these visits.

Further, for patients with two or more chronic conditions, healthcare delivery becomes a lot more complex for the following reasons:

• The conditions can interact with each other, complicating lifestyle and medication management.
• There is a significantly higher risk of acute exacerbations.
• Multiple teams and specialists are involved in managing the conditions.

Chronic Care Management (CCM) programs help address these challenges by providing the framework to effectively manage and coordinate care between in-person visits for patients with multiple chronic conditions.

What Is Remote Patient Monitoring?

Remote Patient Monitoring (RPM) allows providers to monitor patients’ general health and vital signs outside traditional clinical settings. Your patients can get personalized care wherever they are, such as at home.

You'll typically need devices to measure and transmit patient data, communication tools to directly interact with patients, a clinical team to provide ongoing remote support, and a central cloud platform to aggregate the data and processes.

Remote Patient Monitoring relies heavily on connected devices such as:

• Continuous glucose monitors (CGMs) and/or connected glucometers for diabetic patients.
• Bluetooth- or cellular-powered blood pressure cuffs for hypertensive patients.
• Pulse oximeters for patients with respiratory conditions.
• Connected weight scales.

The main goal of RPM, therefore, is to help you monitor your patient's condition in real-time so you can provide proactive, timely interventions to improve patient outcomes.

Also, RPM is incredibly useful in expanding access to care in underserved populations like remote rural areas.

Key Differences and Similarities Between CCM and RPM

CCM and RPM are similar in that they can help you extend your reach beyond the clinic walls. They also share the following attributes:

• They both aim to enhance patient-centred care.
• They are both used in managing chronic conditions, allowing you to provide non-face-to-face services in between in-person visits.
• Medicare recognises both and provides clear reimbursement guidelines.

However, they differ when it comes to primary focus, patient eligibility, and billing/reimbursement requirements.

Let's explore these key differences:

• Primary focus: RPM focuses on monitoring real-time physiological data. CCM helps with comprehensive health management and care coordination for patients with multiple chronic conditions.
• Patient eligibility: A patient with any acute/chronic condition that requires monitoring will generally be eligible for RPM. In the case of CCM, the patient must have at least two chronic conditions that are expected to last for at least 12 months, or until the patient passes away.
• Billing/reimbursement: You bill for CCM primarily on a time basis, where there's at least 20 minutes of non-face-to-face services. Billing for RPM involves the monthly code for the device and data transmission (at least 16 days of data in a 30-day window) and time spent reviewing the data (at least 20 minutes).

That said, you can roll out RPM and CCM services together to expand and integrate chronic care delivery. KangarooHealth supports RPM and CCM, alongside other offerings such as Principal Care Management (PCM), Remote Therapeutic Monitoring (RTM), and Advanced Primary Care Management (APCM).

Benefits of Integrating CCM and RPM Programs

Healthcare providers using CCM and RPM programs have reported significant transformations in care delivery and outcomes.

Let's look into some benefits you can expect from integrating these services:

Significant Improvements in Patient Outcomes

Using CCM and RPM, you can transition from a reactive healthcare delivery model to a proactive one. You'll have complete visibility of your patients’ conditions.

You can engage them in real-time to improve adherence, adjust treatment plans, and reduce the likelihood of acute episodes to avoid hospitalizations.

For instance, a study on whether telemonitoring can reduce hospitalizations and the cost of care among patients with heart failure reported significant reductions in the probability of all-cause admissions and cost of care.

The odds of the telemonitoring group experiencing 30-day and 90-day readmission were 44% and 38% lower, respectively.

Enhances Patient Engagement and Satisfaction

Patients want to be active participants in their healthcare journey. CCM and RPM tools allow them to exercise more control, improving adherence and personal satisfaction.

A study evaluating patients’ overall experiences and satisfaction with an RPM program for acute and chronic conditions reported that 93.58% were satisfied. Notably, 92.76% of the participants would recommend RPM to others with similar conditions.

Lowers Costs for the Provider and Patient

High-cost events like hospitalizations and ER visits significantly burden the provider and patient. CCM and RPM are pretty effective at preventing these events.

In the study that saw 44% and 38% lower odds of 30-day and 90-day readmissions, the corresponding cost savings were about 11% for the payor.

That’s why most providers will find CCM and RPM programs sustainable. Besides being able to cover their own costs, they can generate a positive return on investment.

For instance, a study examining the financial sustainability of remote patient monitoring for hypertension saw an estimated 22.2% positive ROI.

How to Implement Combined CCM and RPM Initiatives

An integrated CCM and RPM implementation is a powerful way to keep patients engaged between visits, significantly boosting adherence and improving outcomes.

Here's how to go about the implementation:

• Define program goals: Do you want to reduce hospitalizations? Do you want less staff burden? How about quality metrics? Get specific on the objectives you want to achieve.
• Identify the patient population: CCM applies to patients with two or more conditions. Which chronic conditions do you want to be onboarded in the program?
• Choose an RPM and CCM partner: You want a partner that can provide an all-in-one RPM and CCM platform. The platform should also integrate with your Electronic Health Record (EHR). KangarooHealth offers an all-in-one platform and also handles RPM device procurement and distribution.
• Establish workflows: With the help of your platform partner, you can define roles in the new program, establish clinical protocols, and train staff. Ideally, you should aim for minimal disruptions to your legacy workflows.
• Enroll patients: Distribute devices and sign up patients on the cloud platforms. You also want to educate patients on the “why” behind the program and provide adequate training on how to use the tools.

Once you onboard the patients and launch the program, you can now focus on continuous data review, patient engagement and education, and treatment plan optimization to improve patient outcomes.

How to Choose the Right CCM and RPM Platform

A CCM and RPM platform is like an extension of your care team. You should take the time to ensure a perfect fit just as you would when interviewing a potential team member.

Let's explore some of the key factors you should pay attention to when choosing a platform provider:

• Current workflows: What do your current workflows look like? Can you onboard the RPM and CCM platform without completely disrupting your established workflows?
• Integration capabilities: You want the platform to integrate seamlessly with your Electronic Health Record (EHR) so you can centralize data and remove manual data entries.
• Rural compatibility: Do you provide care in rural areas with unreliable connectivity? You want to work with a provider that uses cellular-powered RPM devices that don't require patient-provided Wi-Fi or Bluetooth to transmit data.
• Real-time alerts: You want to be notified immediately when your patients’ vital signs are out of range. Your chosen platform should have tailored escalation protocols so you can receive actionable tiered alerts.

Most importantly, you should have clarity on whether you want a platform only or need other vendor services to accompany it. In a DIY scenario, you would be responsible for all RPM and CCM roles, including device procurement and patient enrollment.

However, when you partner with KangarooHealth, you get a full-service remote patient care solution. We handle device selection, procurement, and distribution, provide comprehensive staff and patient education, and use our clinical staff for ongoing patient monitoring and support.

Our approach significantly reduces provider overwhelm, allowing you to focus on what matters most - providing world-class patient care. Schedule your free demo of KangarooHealth's all-in-one CCM and RPM platform today.

Challenges in CCM and RPM Integration

CCM and RPM implementation isn't always smooth sailing. Some challenges are to be expected during the transition, but you can overcome them if you plan ahead and work with the right platform partner.

Let's look into these hurdles and how we can overcome them:

• Billing complexity: Navigating all the relevant documentation and CPT codes can be challenging. KangarooHealth automates tracking and has built-in documentation tools to ensure accurate, compliant billing.
• Tech adoption problems: CCM and RPM programs are tech-heavy. Both your staff and patients may have problems adopting the new technology solutions. KangarooHealth provides comprehensive training and support to ensure every user is equipped to succeed.
• Staffing limitations: The staff hours required to identify, enroll, coach, and monitor patients are significant. We reduce your workload by having our dedicated clinical staff handle most non-face-to-face tasks, so that you can focus on actual patient care.

Frequently Asked Questions (FAQs)

Let's now answer some common questions about chronic care management and remote patient monitoring:

Can CCM and RPM Be Used in Nursing Homes or Assisted Living?

Yes, Medicare allows you to provide CCM and RPM services to nursing home and assisted living facility residents.

You can do this provided the place of service (POS) when billing is your clinic/practice, and the patient is not in Medicare Part A.

What Is the Average ROI for Clinics Using CCM and RPM?

Return on investment for CCM and RPM programs varies widely depending on the platform provider, location, number of patients enrolled, and how much of the operations you outsource.

Since the most significant source of returns is reimbursement for CPT codes, KangarooHealth provides tools to streamline tracking and billing so you can be reimbursed for all the qualifying remote care you provide.

How Do RPM and CCM Help in Reducing Emergency Room Visits?

RPM and CCM give you real-time visibility into your patient's condition.

Instead of being reactive after things get critical, you can spot warning signs early and intervene before the patient's condition worsens.

Conclusion

As value-based care evolves, chronic care management and remote patient monitoring are becoming expected standards for every healthcare organization committed to patient-centered care.

You can now implement these remote patient care programs without bearing the staff or technology burden alone. With KangarooHealth by your side, your RPM and CCM implementation can be rolled out in under two weeks.

Discover how KangarooHealth's proven remote patient care solutions can transform your practice. Book a free demo today, and our team will walk you through our comprehensive CCM and RPM platform.