Empowering patients through ChartSpan’s Chronic Care Management

Patients in remote areas need consistent access to care

Located three hours west of Dallas, Abilene Family Medical Associates serves thousands of patients from Abilene and surrounding rural areas. Because many of their patients live up to 30 miles from the practice, “there aren’t a lot of resources around, and patients sometimes find it difficult to get in for appointments,” said Vickie Meyers, Director of Operations.

Abilene Family Medical Associates knew they needed to offer patients preventative care between appointments, including medication management and support for common chronic conditions like diabetes and high blood pressure. They turned to Medicare’s Chronic Care Management as a solution.

ChartSpan offers robust preventative care through Chronic Care Management

Chronic Care Management (CCM) is a program created by CMS to bring preventative care to Medicare patients with two or more chronic conditions. Its goal is to improve these patients’ outcomes through ongoing care. ChartSpan, an athenahealth Marketplace partner, offers a Chronic Care Management program that includes care managers who reach out to Abilene’s enrolled patients remotely every month. Patients can also call or text the 24/7 care line when they have questions or concerns about their symptoms.

When Vickie Meyers joined Abilene Family Medical Associates, she was immediately impressed with their established ChartSpan program and its workflows. The program ran smoothly with Abilene’s internal processes and technologies. She was especially impressed with ChartSpan’s bi-directional integration with athenaOne’s EHR. “Information transfer is seamless, along with the workflow. The flow is exceptional,” she said.

ChartSpan’s athenaOne integration empowers practice staff to address CCM program notifications directly within the EHR, using the athenaPatient® mobile app. While this feature is optional, it can help expedite bidirectional communication with the ChartSpan care team and keep messaging within the practice staff’s daily interface.

Beyond the technical success of a seamless EHR integration, Meyers emphasizes the tangible value of the CCM program for patients, notably in streamlining medication management, facilitating transportation services, and supporting the management of their chronic conditions.

Since ChartSpan care managers conduct monthly outreach to patients, they can often identify when patients haven’t refilled prescriptions or haven’t consistently taken their medication. “ChartSpan has picked up on some of those medication errors, so we can fix them before the patient ends up in the emergency room,” she stated.

ChartSpan’s care managers can also help with arranging transportation services, a critical option for patients who live in remote areas and aren’t able to drive, and with notifying Abilene about symptoms like high A1C or high blood pressure in between appointments. “It’s a great program to get patients back to us when they have changes we need to know about,” Meyers said.

It’s a good program, and patients need it. The help with transportation issues and listening to patients between appointments has been really beneficial.

Increased revenue, staff time savings, and improved quality measures

ChartSpan has helped Abilene Family Medical Associates achieve improved revenue and quality measures, without increasing workload for their staff. Abilene Family has seen revenue growth of more than $26,000 a month as they offer their patients additional help with community resources, medication refills, and appointment scheduling.

Thanks to ChartSpan’s team managing many incoming patient requests, Abilene has been able to offer CCM services without overworking their staff. “We have such a demand on our telephone and our portals. [ChartSpan] really helps us on that end,” Meyers said.

The ability to access care 24/7 through ChartSpan has helped reduce patients’ unnecessary visits to the emergency room. This benefits patients, who are spared from a stressful and expensive ER visit and helps improve Abilene Family’s ACO quality measures.

“Patients get scared and go to the ER when it can be completely avoidable,” Meyers said. ChartSpan’s 24-hour care line gives patients the opportunity to speak to the care team if they have concerning symptoms. The care team can connect them to a nurse for triage if needed, and the triage nurse can direct them to the appropriate level of care. Sometimes that means visiting the ER, but other times they can be directed to urgent care or back to the practice.

Meyers concluded, “We get a lot of phone calls from Medicare patients, and CCM has helped keep them out of the emergency room and coming back to us.” In this way, CCM supports Abilene Family Medical Associates’ mission of providing exceptional care in a primary care setting.

Curious how you can achieve similar results?

Explore our marketplace solutions and join the 39 athenahealth customers who are already seeing the benefits of ChartSpan’s Chronic Care Management. Let’s chat about how we can partner for your success.