Chronic Care Management, Inc.
Closing the "In-Between Visit" Care Gap

A patient with a chronic disease like hypertension, diabetes, arthritis, or hypothyroidism typically needs to stay under constant care, keep track of their health conditions, and make frequent visits to their healthcare provider. But what happens to that patient in between visits? Some of the clinicians adopt different forms of chronic disease management strategy that engage patients in between visits and aim to quell the negative impacts of their illness. But despite the universal imperative for chronic care management, that feat remains difficult for some providers than others. A clinician, for instance, might lack the personnel to deliver comprehensive chronic disease management on his own, even though he may have just as many chronically ill patients as a large primary care practice. This is where William Mills, M.D., a board-certified physician with first-hand experience in treating patients with chronic conditions stepped in. Passionate about transforming the chronic care management arena, he wanted patients and healthcare providers to recognize the importance of “in-between visit” patient care and reimagine the way current quality care management programs function. Wielding this vision into reality, Mills founded Chronic Care Management, Inc. (CCM) in 2014.

As a home-based primary care doctor, Mills has personally made more than 20,000 house calls throughout his career. This experience of catering to patients with complex healthcare needs is further fortified by his know-how as the chief medical officer of a Fortune 500 company, president of a population health management group, and board member of a leading national non-profit organization. All these diverse experiences helped Mills build a next-gen chronic care management offering.

"Our chronic care management technology supports risk stratification as well as multiple levels of chronic care management complexity"

Along with a multidisciplinary team of clinicians and digital technology experts, Mills—CCM’s president and CEO—has created a comprehensive software solution with clinically-integrated care management programs that promote goal-directed, and quality collaborative care planning for patients with chronic diseases. “CCM helps healthcare practices navigate the complexities of chronic care management, while providing a path for new reimbursement through programs for both fee-for-service and value-based care, while simultaneously recognizing the importance of in-between visit care,” highlights Mills. Further, by bringing together clinicians and other healthcare stakeholders on a central node (platform), the solution aims to deliver a person-centered care plan that drives positive clinical results for patients, and boosts financial outcome for healthcare organizations and payers, including Medicare.

CCM helps healthcare practices navigate the complexities of chronic care management, while providing a path for new reimbursement through programs for both fee-for-service and value-based care

That said, CCM also offers a concrete path for healthcare institutions to realign their approach from a fee-for-service to a fee-for-value model through their platform offerings—care coordination, advanced care planning, and medication reconciliation— “thereby streamlining and personalizing chronic care management,” asserts Mills.

Simplifying Chronic Care Management

More often than not, chronic disease care management has been disjointed, with poor coordination between providers, treatments, and the settings of chronic illness care. In addition to that, the complicated nature of chronic illness, coupled with its numerous protocols has been a challenge for clinicians to comply with. This is where CCM has been able to make a world of difference. “As a team of care management expert physicians, we have been exposed to all the opportunities, challenges, workflows, and the regulations and policies associated with treating chronically-ill patients,” remarks Mills. Putting this knowledge and experience into practice led to the genesis of CCM’s technology and services platform. A solution for in-between visit care for high-risk patients with multiple chronic conditions, CCM’s platform offers all the solutions needed for management services organizations (MSOs), accountable care organizations (ACOs), and post-acute care, including health systems, group practices, and solo practitioners. “Our chronic care management technology supports risk stratification as well as multiple levels of chronic care management complexity,” explains Mills.

Every care management activity within the platform is time-tracked. In the case of third-party audits, drill down of every time-tracked interaction can easily be shown to the auditor. Alongside, healthcare practitioners have access to a robust reporting module where they can check their progress each month.

However, one of the aspects that uniquely positions CCM’s comprehensive solution in the care management universe is its ANNA Connected Care feature, which is designed to enhance connectivity between providers and their care teams who are supporting chronic care management episodes. ANNA Connected Care enables clinicians to efficiently connect with high-risk patients and review their care plans. The application also helps healthcare practitioners to connect or refer their patients to valuable services like home care, physical therapy, palliative care, hospice, specialists, and more. Together with that, the platform also offers a feature called “My Wishes, My Words.”

The distinctive feature aims to place the patient’s care management goals, providing an important context of the care direction in patient’s own words.

Coupled with the comprehensive solution, CCM provides complete consultative and advisory guidance to healthcare providers. CCM’s trained, U.S.-based clinical staff works as an extension of a healthcare provider’s care team, and collaborates with the practitioners. CCM’s experts periodically conduct a formalized review on the care management parameters with the clinicians to address each of their challenges. “We continually train our staff on the complexities of CCM so you can focus on patient care instead of being bogged down by the complex CCM documentation and time tracking requirements,” says Mills.

Bringing In Portability to Chronic Care Planning

Due to fragmentation in the healthcare industry, it has been almost impossible for clinics and health systems to develop a portable care plan for patients with chronic conditions. “And when care plans are not portable, patients often face frustrations like lack of goal-directed care, non-transferrable code status, duplication of tests, and redundant questions on even the most basic areas of health history,” says Mills. CCM aims to resolve these concerns seamlessly as all their care plans are entirely portable—and are available for use wherever and whenever needed. Highlighting the value proposition of this facet in the care management regime, Mills notes, “This degree of portability not just solves the duplication problem, but also assures the enablement of a uniform goal-directed care across multiple places of service.”



CCM also helps in the development of “Connected Homes” for patients in any care setting, which can provide tailored physiological monitoring that specifically aligns with a patient’s chronic conditions. The remote patient monitoring data, upon a practitioner’s review, is incorporated into the care plan. This approach provides direct clinical value to patients and the much-needed chronic disease management support that can help keep patients at home, away from high-cost settings like emergency rooms and hospitals.

Empowering Patients with Long-Term Care Plans

Mills believes that long-term care and assisted living residents can benefit the most from CCM’s chronic care management programs. Patients staying in nursing facilities typically have numerous chronic conditions, and many of them are even affected by memory impairment, gait disorders, and experience mood fluctuations. While dedicated nursing staff, caregivers, and practitioners do their best to provide sound management for this population, there are many acute issues which are yet to be addressed. This is where CCM can help. “At CCM, we understand the setbacks of this patient population and offer best-in-class care programs for your practice,” says Mills. Currently working with a number of long-term care practices of various sizes—from small groups to large national practices—CCM has already developed leading workflow solutions. “As the niche of this practice further strengthens, we are poised to usher a redefined approach to the senior population’s care planning and management,” affirms Mills.