Condition Management: Patient Services
The Care Coordination Institute (CCI) is committed to partnering with physicians, hospitals, and other health care providers to transform the health of communities through facilitation and education around coordination of care, evidence-based best practices and the promotion of healthy lifestyles. The goal of the program is to support the practitioner/patient relationship and plan of care through risk management and establishing healthy lifestyle behaviors. Care Coordination Institute offers condition management programs for patients who are identified with diabetes, congestive heart failure, chronic obstructive pulmonary disease, asthma, hypertension and hyperlipidemia.
A patient in the program will receive educational materials and in-person meetings with a health coach. A health coach will assist patients in developing an action plan and help them understand and manage their medications. The health coach will also keep the patient’s healthcare providers informed of their action plan, goals and progress. The information a patient receives through this program does not replace their provider’s care. A patient must still discuss any questions or concerns they may have with their provider.
The Condition Management program is not an emergency provider. If a patient needs urgent care, immediately call a physician, go to an emergency department or call 911. For non-urgent care, please contact Condition Management at (844) 808-9347.
The condition management program is voluntary and provided at no cost to you. Patients may opt out of the program at any time by calling Care Coordination Services at (864) 522-2060 or by emailing firstname.lastname@example.org. Care Coordination Institute’s Condition Management Program does not market, advertise or promote any products or services. Condition Management protocols are developed using best practice guidelines. CCI does not represent, warrant, undertake or guarantee that the use of services or products will lead to any particular outcome or result.Formal complaints or feedback must be submitted in writing to Care Coordination Institute by emailing email@example.com. Complaints will be addressed within 72 hours.
Condition Management: Program Operations
CCI’s Care Coordination Services supports the patient-provider relationship and plan of care, while emphasizing the prevention of disease progression and complications using cost-effective, evidence-based practice guidelines and patient empowerment strategies such as self-management tools. Clinical data sources are utilized to assess and proactively identify a patient that is living with or at risk for complex and/or chronic medical conditions. All data collected through the assessment process will be stored within the patient’s electronic health record (EHR) and will be utilized to place the patient into the appropriate risk category, thereby determining the level of involvement employed by Care Coordination Services staff. Patients are selected for Care Coordination Services through diagnosis complexity, identification of barriers to improved health, compliance with treatment plan and high use of resources. Patients receive Care Coordination Services in an effort to improve overall health status, improve satisfaction and improve efficient use of resources.
By participating in Condition Management, the patient agrees to work with their providers, as well as the Care Coordination Services staff. The patient must acknowledge and agree to a care manager or health coach reviewing medical and prescription drug claims, lab results, health risk appraisals, and EHR data to identity opportunities for prevention or intervention. The patient will be engaged by program staff at least once by phone. The exact frequency of these engagements will be determined by the patient’s risk level and preference.
Patients enrolled in Condition Management will primarily receive information regarding self-management actions by phone. All interactions will be documented in the patient’s EHR. A patient may, at any time, request a copy of this record. Formal recommendations, referrals for Care Coordination Services, and other services will initially be communicated by phone and will be documented in the patient’s EHR in the same manner as all other interactions. Upon enrollment, the patient will receive a self-management action plan with goals agreed upon by the patient and members of the healthcare team, including the patient’s primary care provider. Progress will be evaluated at every encounter, and a revised plan will be given to the patient and will be documented in the EHR.
In certain situations, incentives and discounts may be available to those with certain chronic conditions. Participation is voluntary and, if at any time the patient chooses to stop participating in the program, he or she may opt-out. The patient acknowledges that, if he or she chooses to opt out of the program, he or she will forfeit specified incentives and discounts.
Care Coordination Services abides by state and federal regulations that govern the disclosure of information to third parties. If information must be disclosed to third parties, the request must be obtained in writing and only the requested information will be transmitted. The patient will be informed within 72 hours by phone about the disclosure of information.
Condition Management: Practitioner Services
The Care Coordination Institute (CCI) is based in Greenville, South Carolina and is committed to partnering with physicians, hospitals and other healthcare providers to transform the health of communities through facilitation and education around coordination of care, evidence-based best practices and the promotion of healthy lifestyles. Our goal is to have a positive impact on quality, healthcare costs and the patient experience. The Condition Management program, a care coordination service offered through CCI, is available to eligible patients who are identified for diabetes, congestive heart failure, chronic obstructive pulmonary disease, asthma, hypertension and hyperlipidemia.
The program is designed to collaborate with practitioners and patients to identify opportunities for prevention and intervention to provide well-coordinated care. Patients enrolled in the condition management program will work with a health coach to develop a plan of care founded on evidence-based guidelines and interventions specific to their conditions or risks. Intervention plans are tailored based on screenings, immunizations, self-management education and support, medication adherence and goal-setting. The health coach will encourage adoption of healthy lifestyle behaviors and assist the patient with referrals to support groups and condition-specific programs including diabetes self- management, medical nutrition therapy, weight management, smoking cessation, and depression. The health coach will interact with patients through phone calls or in person meetings. Educational materials are given to support all self-care efforts of the patient.
As a practitioner, the health coach will provide you with the care plan for your patient, along with updates on the progress of your patient through their electronic medical record (EMR), via fax or postal services. Utilizing this service allows you to partner and communicate with your patient’s health coach to provide feedback or concerns regarding the well-being of your patient. Unscheduled communication between you and the health coach may occur if clinical questions arise concerning the patient’s medication or if there are immediate concerns about your patient’s safety.
Questions, concerns or complaints can be sent to firstname.lastname@example.org or call (844) 808-9347. Our hours of operation are Monday through Friday from 8-5 p.m.