In Clinic Workflow
Step 1 (Inform): Front Desk
🚩Flag eligible patients in EHR
📝When an eligible patient arrives, hand them the CCM packet and inform them of the new program (doctor will discuss the program with them).
Step 2 (Educate): Nurse & Provider
📝Nurse/MA recommend CCM & put Phamily Prescription Sheet in visible place for provider.
In the waiting room review the program with the patient and let them know they are eligible
✏️Provider refers patient to CCM & confirms verbal consent or marks deferral.
⭕If consenting, outline chronic conditions & discuss 3 health goals w/ patient.
💲Bill for G0506 and record chronic conditions & goals on the Phamily Prescription Sheet.
📃Deliver CCM Program Enrollment Form (tri fold brochure) w/ one pager and document verbal or written consent.
🗂️Deliver Phamily Prescription Sheet to the Care Manager.
Step 3 (Enroll): Care Manager
👥Before the patient leaves the clinic, add and enroll them to Phamily (send welcome message).
📝Create and share a care plan by adding the patient's chronic conditions of focus and 3 health goals.
💻The Phamily system will take over from there.
Connected Care Talking Points
What is Connected Care?
The Connected Care service is a Medicare program designed to provide extra support for patients with chronic conditions such as diabetes, heart disease, high blood pressure, arthritis, etc. It gives you access to a dedicated care team between regular visits. You will get regular support and education via text & calls. You can also message your care team directly for any questions or concerns at your convenience without having to come in for routine things. Connected Care reduces hospital visits and helps keep patients healthy.
Patient Benefits:
Text us any time. No more phone tag.
Handle all the little things faster without waiting for a call back or scheduling a visit
Text us for help with:
Scheduling appointments, follow-ups, and sick visits
Questions about your health, medication, and symptoms
Requests for refills, referrals, lab results, and more
A dedicated care team to support you with things you need between visits.
Personalized care plan to help you achieve your health goals
Standard Medicare cost sharing applies, but most patients have secondary insurance that cover copays.
Consent:
Before billing for CCM services, obtain the patient’s digital, written or verbal consent. You must also inform them of the following and document it in their medical record:
Availability of CCM/PCM services
Possible cost sharing responsibilities
Only 1 provider can furnish and bill CCM/PCM services
You can stop CCM/PCM services at any time (effective the end of month
CCM Enrollment Phone Scripts
Front Desk: Introduce the program
"Hi [Patient], we're now offering a Medicare program called Connected Care that you can discuss with [Provider]. Please review this information and you can discuss enrolling with your provider during the visit!"
*Note: Keep it short and to the point. No need to go into too many details, the nurses and providers will take care of that!
MA/Nurse: Recommend the Program
"Hi [Patient], [Provider] has asked me to discuss Medicare's Connected Care Program with you. [Provider] is recommending you enroll to better manage your [Condition 1] and [Condition 2] between visits at the office.
Connected Care allows our Care Manager [NAME] to check in with you via text between visits and help with anything you need. We find that patients like you that participate in this program are more likely to improve their [EXAMPLE HEALTH ISSUE] and general health over time. We can also help you via text with common needs like medication questions, medication refills, and more. The program is simple and doesn’t require much from you other than your response.
During your visit today [PROVIDER] will review the program and a few specific health goals for you to follow for the coming months. We’ll then turn these goals into a care plan you can use to better manage your own health at home. From there, your Care Manager will be reaching out to you via text message at least two times per week to check-in on you and make sure you’re doing okay. You should reply as much as you can to keep us up to date on how you’re feeling, so that we can keep you healthy and out of the ER.
This is a Medicare program so standard cost-sharing applies just like it does for your visits, appts, or meds.. The good news is that most patients have supplemental insurance coverage to cover most of, if not all, of the co-pay.
[PROVIDER] is going to discuss the program and go through your goals but I strongly suggest you participate. It’s really helpful.”
*Note: Emphasize that this is something the provider thinks the patient needs
Provider: Prescribe the program
"To help us provide you with better care and guidance between your visits I’d like to have you enroll in our Connected Care program. That way our Care Manager will be able to keep in close contact with you to make sure you have everything you need to stay healthy. For example, you can text us with questions regarding your [MEDICATION OR CONDITION SPECIFIC TO THE PATIENT] or anytime you are having issues with [SYMPTOM, ETC.]
I’ll have our Care Manager create and share a custom care plan for you after the visit. While I have you here I’d like to go over three health goals we can work on for your first few months in the program."
*Note: Review the benefits of CCM with the patient and identify three health goals
See also
In Clinic Workflow
Need help?
Contact our Support Team at support@phamily.com, or click the question mark in Phamily, for assistance.