Start your care management service with athenaOne®

athenaOne helps physicians care for patients managing chronic diseases

Chronic conditions like diabetes, hypertension, and heart disease are on the rise, affecting millions of Americans and placing significant demands on the US healthcare system. In fact, according to the CDC, six in 10 Americans have at least one chronic medical condition; four in 10 have at least two.¹

Helping your patients manage their chronic conditions is a critical component in delivering comprehensive, patient-centered care. Successful care management not only improves patient outcomes but also reduces healthcare costs by minimizing hospitalizations and emergency department visits. Running a care management program also adds a potential revenue stream — the Centers for Medicare & Medicaid Services (CMS) offers a value-based care (VBC) program specifically designed to reward chronic care management services.

However, there are challenges to this type of work. Getting a high-level view of your patients who will benefit from care management can be difficult, especially if you’re dealing with unconnected systems and disparate data. Keeping patients informed and engaged is also key but can be time-consuming. However, you can solve these challenges and others with the right planning and technology-enabled support.

Enter athenaOne, a powerful solution designed to help you succeed. We’ve designed our technology and services to help you provide the best possible care to your patients, whether they have few medical needs or are managing multiple chronic conditions.

Is it time to start your chronic care management service?

Benefits of providing managed care

Care management can enhance the quality of care you provide to patients, especially those with multiple chronic conditions. These types of programs can enable you to deliver more personalized support, stay in better communication with patients, and proactively address potential health issues before they escalate. They can also help you identify and address the social determinants of health (SDoH) that impact your patient population.²

Careful care planning and management not only help reduce hospitalizations and emergency visits but can also create additional revenue streams through reimbursements for care coordination services. This is a great way to start or continue testing a more value-based methodology of care. Chronic care management (CCM) is an excellent example of a healthcare approach that prioritizes high quality over high volume (a hallmark of the pervasive fee-for-value model) while still driving revenue.³

Chronic Care Management program from the Centers for Medicare & Medicaid Services

If Medicare recipients make up a significant portion of your patients, consider CMS’ value-based Chronic Care Management program.⁴ The program is designed to provide code-based reimbursements for non-face-to-face care coordination services for Medicare beneficiaries with multiple chronic conditions.⁵

If you don’t see many Medicare patients, a chronic care model may still be worth pursuing — many practices utilize care management programs even if they don’t participate in the CMS model. Either way, your success will depend in part on the healthcare IT (HIT) you have in in place.

athenaOne for chronic disease management support

athenaOne is our all-in-one software and service solution, built with interoperability at its core and plugged into the vast athenahealth® network. athenaOne is more than an electronic health record (EHR) platform — it combines robust EHR capabilities with sophisticated patient engagement and practice management tools.

Here are a few ways athenaOne can help you administer a successful chronic care management program.

Predict and identify patients who will benefit from care management

If you’re looking to stand up a care management program, your first question should be, “Who is this for?” That is, do you have the right mix of patients to warrant such a program? And can you identify and enroll new patients as they become eligible?

To find this information, athenaOne users have access to our robust reporting capabilities which they can use to identify CCM-eligible patients. Similarly, athenaOne can produce reports based on Hierarchical Condition Categories (HCC) codes, so you can quickly see which of your patients have conditions like asthma, arthritis, diabetes, kidney disease, hypertension, obesity, and others.

Coordinate and deliver excellent care to patients, directly from your EHR

Care coordination is a hot topic in US healthcare, and for good reason: more effective coordination between providers, labs, hospitals, and other healthcare entities will help solve some of the thorny issues at the heart of the US healthcare system.

According to CMS, care coordination, “can help to keep patients healthier longer, better manage chronic conditions and experience care that is consistent with their goals.”⁶ It’s for these reasons that CMS rewards care coordination in many of its value-based care programs.

One of the great benefits of using athenaOne for care management is that you can work directly within the EHR solution, rather than moving between patient records and a separate, unconnected chronic care management platform. athenaOne features direct integrations with many of the largest healthcare payers in the US, so data is transferred accurately and efficiently.

Six in 10 Americans have at least one chronic medical condition; four in 10 have at least two.

Not only is this a good value — it also helps keep your data accurate, up-to-date, and in one place. For example, athenaOne’s ChartSync tool consolidates patient information, so you have trusted access to a complete view of a patient’s medical history, medications, and previous treatments. This holistic view can form the basis for an effective care plan.

athenaOne is also designed to deliver the right information, in the right place, at the right time. This timely information comes in many forms, including encounter documentation, encounter plans and templates, and other clinical decision support. The system even surfaces care gaps directly in the patient chart.

athenaOne care plans

Our platform includes templated, condition-specific workflows for creating tailored care plans for your patients, including outlining goals, interventions, and follow-up actions. These care plans are embedded in the platform so you can create and enroll patients in a plan directly from their chart. The plan can then be shared easily with patients via the Patient Portal or sent directly from your encounter workflow.

Since billing for certain CCM services is time-restricted, athenaOne also enables tracking with our CCM timer so you can accurately account for the minutes you spend working directly with your patient, documenting in their care plan, and coordinating further care.

Extend access and convenience with athenaTelehealth

Patients dealing with multiple chronic conditions can benefit from a mix of in-person office visits and virtual appointments. Care planning for these patients may require frequent check-ins with their care team, which can greatly improve outcomes. However, frequent visits can also add stress to patients who are busy or have mobility restrictions. That’s why offering telehealth alongside in-person visits is so valuable for chronic care management, and why we’ve embedded our athenaTelehealth solution within athenaOne.

Engage patients with enhanced access and self-management tools

Engaging patients between appointments is crucial for effective chronic care management. High levels of patient engagement can lead to improved adherence to care plans, increased patient satisfaction, and ultimately better outcomes from your care management program.

The athenaOne Patient Portal serves as a primary digital engagement tool for patients, offering essential resources to help them manage their chronic conditions effectively. With 24/7 access to their health records, lab results, medication information, and appointment details, patients can stay informed about their health at all times. The portal enables patients to send secure messages to you and your staff for specific health-related inquiries, request prescription refills, and schedule future appointments, whether in-person or via telehealth. They can even access portal tools and information on the go with the athenaPatient™ app.

Additionally, the Patient Portal provides educational materials tailored to individual health conditions and treatments. By offering relevant and accessible information, patients can gain a better understanding of their health, empowering them to make informed decisions about their care and actively participate in their chronic care management.

Tailored capabilities through the athenahealth Marketplace

Our goal is to give you and your staff the most tailored, need-driving technology possible to help you achieve your goals and deliver excellent care to patients. That’s why athenaOne is so customizable — and why we’ve extended your ability to customize via the athenahealth Marketplace. The Marketplace features more than 550 Partners that integrate seamlessly into athenaOne, including those that offer chronic care management tools and services, like remote patient monitoring, that can help your care management program succeed.⁷

The power of the athenaOne network for chronic care management

The athenahealth network also plays a crucial role in helping clinicians effectively manage chronic conditions for their patients. With over 20% of the U.S. population served by providers using athenaOne, clinicians gain access to a vast network that facilitates seamless data exchange among healthcare professionals, pharmacies, labs, and payers.⁸ This connectivity ensures that clinicians have comprehensive patient information at their fingertips, enabling informed decision-making.

By leveraging insights and best practices from a community of over 160,000 providers, clinicians can optimize their care strategies for chronic condition management.⁹ The system offers data analytics and reporting tools that track performance metrics, identify trends, and assess the effectiveness of interventions, fostering continuous improvement in patient care.

Additionally, this massive network produces valuable data, enabling athenahealth to share insights on topics like prescription rates and the seasonal spread of the flu.

Consider athenaOne as your partner in providing more patient-centric care, including chronic care management.