This document describes a chronic care management program called CareConnect ChronicCare 360 that utilizes remote patient monitoring (RPM) and telehealth. It provides an overview of the chronic care management model, benefits of RPM, technology challenges, and perspectives from patients and providers. Key aspects of the program include remote monitoring of patient vitals using connected devices, virtual visits with care coordinators and providers, and a care team approach to managing enrolled patients with chronic conditions. Workflows around patient enrollment, device setup, data monitoring, and billing codes for RPM services are also outlined. The goal of the program is to improve outcomes for patients with chronic diseases through remote care management and coordinated care between visits.

1. Chronic Care Management
Through Telehealth
Ajay Gehlot, CEO and Clinical Director

2. Chronic Care Management Model
● Self-Management Support
● Deliver System Design
● Decision System
● Clinical Information System
● Organization of Health Care

3. Closing the Gap
RPM
CCM
Virtual
Visit
• Self-Management: Patients Become
True Partners and Effective
Managers
• Delivery System: Real Time
Information
• Decision System: Shared Decision
Making
• Clinical Information System: Registry
• Organization: Aligned with QI

4. CareConnect ChronicCare 360

5. CareConnect
ChronicCare 360
Benefits and Challenges of Program
Devices
Patient Perspective
Provider Perspective
Team Members
Work Flow
Enrollment and Billing

6. Benefits of RPM
● Improved Quality of Care
● Better Patient Outcomes
● Real Time Management
● Reduced Readmissions and ED Visits
● Easier Access to Care

7. Benefits of RPM
Patient Perspective
43%: Greater convenience as a major benefit
39%: Cited efficiency
37%: More control over personal health
36%: Accuracy or peace of mind
MSI international Survey (May 2021) - 300 patients

8. Techonolgy Challenges of RPM
● Data Security
● Data Accuracy
● System Integration
● Cost of Devices
● User Interface and User Experience

9. Perceived Limitations of RPM
Patient Perspective
● Concerns about accuracy of the monitoring technology
● Reliability of the platform
● Cost of care
MSI international Survey (May 2021) - 300 patients

11. CareConnect ChronicCare 360
Patient Perspective

12. Home Screen

13. Home Screen

14. Home Screen

15. Connecting a
Device

16. Connecting a
Device

17. Connecting a
Device

18. Connecting a
Device

19. Scheduling a
Chronic Care
Management
Visit

20. Scheduling a
Chronic Care
Management
Visit

21. CareConnect ChronicCare 360
Provider Perspective

32. CareConnect ChronicCare 360
Team Members

33. ChronicCare Command Center Team
● Sarah Mikell, Provider
● Bridget Mosley,
Clinical Manager
● Tristian Mitchell,
Project Manager
● Mackenzie Turner,
Care Coordinator
● Madison Teal,
Care Coordinator

34. Patient seen by PCP at the office
Patient has one or more chronic diseases
PCP discusses the benefits of ChronicCare 360 –
Patient Agrees to Enroll
Patient is given a “Prescription” for Devices to be
Connected and Configured
Patient is given an appointment to see the
Telehealth Coordinator
Work Flow – Enrollment in the Program

35. Patient arrives with the Prescription and her/his cell
phone/mobile device/Tablet
Telehealth Coordinator (TC) downloads the App on
Patient’s phone, helps them open the account
Based on the “Prescription” TC configures and
connects the devices
Patient is educated about using the devices correctly,
recording the measurements, and using the App
Work Flow – Enrollment in the Program

36. The Data is monitored on a regular basis by Telehealth
Coordinator
Changes in the trend for any patient is brought to the
attention of Telehealth Provider
Patient is “invited” for a Video Visit to see what is going on
Based on video visit findings, Patient may be asked to
see the Primary Care Provider at their regular office in
person
Work Flow – Participation in the Program

37. Forms for the Program
• Prescription Sheet
• Patient Consent and Agreement for Participation
• Device Loaner Agreement

38. CareConnect ChronicCare 360
RPM Patient Enrollment and
Billing

39. Patient Enrollment Criteria
• Patient consent
• FDA registered Devices
• Ordered by a qualified medical professional.
• Patients must record and transmit readings for
at least 16 out of 30 days
• Data monitoring services by a physician, a
qualified healthcare professional, or clinical
staff (RNs/medical assistants)

40. RPM Billing Codes
• Service Initiation: CPT 99453 (Set up and
Education)
• Data Transmission: CPT 99454
• Data Analysis and Interpretation: CPT 99091 (30
minutes each 30 days)
• Treatment Management Services: CPT 99457 (20
Minutes each Calendar Month). CPT 99458 (Addl
20 Minutes)

41. Questions???
Success is a lousy teacher. It
seduces smart people into thinking
they can’t lose.
Bill Gates
CareConnect ChronicCare 360