Common Challenges when Practices Implement CCM Programs

CircleLink Partners with athenahealth to Improve Medicare Reimbursements and Outcomes Through Technology, Data and 100% RN Care Coaches

New York, NY – November 20, 2019 – CircleLink Health, a leading provider of Chronic Care Management (CCM) and Annual Wellness Visits (AWV), today announced a partnership with athenahealth, Inc. through athenahealth’s Marketplace program. As part of the athenahealth® Marketplace, this newly integrated application is now available to athenahealth’s growing network of 120,000 healthcare providers to seamlessly launch new reimbursable wellness programs, like CCM, with CircleLink’s best-in-class RN care coaches.

Here’s what people are saying about CircleLink’s offering:

“What a great service”
– Dr. Jeffrey Hyman FACP, Medical Director, University Physicians Group/Northwell Health

“It has been 16 months of active service with CircleLink. We are already seeing revenue and health improvements.”
– Anne Broumel, Clinic Resource Manager, Wickenburg Community Hospital

“Really enjoy talking to a [CircleLink] Nurse and I think the Medicare program you have me enrolled in is so great. Thank you.”
– Patient, Phoenix (AZ), thanking Physician partnered with CircleLink Health

athenahealth is a network-enabled, results-oriented services company that offers medical record, revenue cycle, patient engagement, care coordination, and population health services for hospital and ambulatory clients. The company’s vision is to build a national health information backbone to help make healthcare work as it should. As a Marketplace partner, CircleLink Health joins a network of like-minded healthcare professionals who are looking to disrupt established approaches in healthcare that simply aren’t working, aren’t good enough, or aren’t advancing the industry and help providers thrive in the face of industry change.

To learn more about CircleLink’s new integrated application, please visit CircleLink’s product listing page on the Marketplace.

About CircleLink Health

CircleLink Health offers software plus telephone nursing for Chronic Care Management (CCM) and Behavioral Health Integration (BHI), as well as tools to boost Annual Wellness Visits (AWV). This allows providers to improve health and earn new Medicare payments (up to $100K+/year per doctor). CircleLink makes it easy by handling patient targeting, enrollment, and integration with various EHRs so doctors can stay on one system. CircleLink uses 100% registered nurses for meaningful remote patient engagement on doctors’ behalf. 

Contact Info
Haziq Ghani
CircleLink Health
(917) 746-2708

New Care Management/CCM Codes for 2020

New Care Management/CCM Codes for 2020

Medicare recently (July 2019) proposed major improvements to Chronic Care Management (“CCM”) and other reimbursable programs, effective Jan. 2020 (source proposal). These changes have the potential to significantly improve practice revenue and patient health (plus lower systemic costs).

Below, we’ve outlined the most impactful reimbursement proposals primary care providers and practice leaders need to know about for 2020.

Check back here in November, when the Medicare proposals are finalized, for an update on what will be included in the final 2020 fee schedule!

Key proposals:

1. TCM (Transitional Care Management) fee increase
2. CCM
a. New code for each additional 20 minutes of care management beyond 20 minutes per month
b. Complex CCM removes requirement for ‘substantial care plan revision’
3. Remote Physiologic Monitoring (RPM) now allows remote/off-site care managers
4. New “Personalized Care Management” for patients with 1 ‘serious chronic condition’

1. TCM (Transitional Care Management) fee increase

TCM incentivizes physicians to follow-up with a patient post-hospital discharge to ensure the patient stays healthy/avoids re-hospitalization. There were nearly 1.3 million TCM claims in 2018, up from 300,000 in 2013, TCM’s first year. However, an analysis by Bindman and Cox found that utilization is still low compared to the number of Medicare eligible discharges. More importantly, the analysis found that beneficiaries who received TCM services demonstrated reduced readmission rates, lower mortality, and decreased health care costs.

To increase clinicians’ use of this valuable care program, Medicare is increasing reimbursements for the codes by as much as 12%:

  • RVU for CPT 99495 increase to 2.36 (from 2.11)
  • RVU for CPT 99496 increase to 3.1 (from 3.05)

2. Chronic Care Management (CCM)

In its recent proposal, Medicare references data showing costs savings and increased patient/provider satisfaction attributable to CCM. Medicare then proposes new codes and changes in the hopes of expanding the program.

a. Most significant is the proposed code “GCCC2” (0.54 RVU) which reimburses “each additional 20 minutes” of needed non-face-to-face follow-up care beyond the first 20 minutes per month. This will allow higher quality follow-ups with patients needing time-consuming care management. For example, CircleLink’s own RNs may spend over 60 minutes in a month coordinating care with a single patient where complex approvals and logistics may be needed, e.g., delivery of medical equipment like an oxygen tank. Other times, a medication reconciliation in addition to detailed patient education/follow-ups may exceed 20 minutes per month but are nonetheless necessary to improve patient health and compliance. This new code (GCCC2) will make sure practices are incentivized to give patients all the follow-up care they need, not just 20 minutes per month.

b. Separately, Complex CCM codes no longer require “substantial care plan revision”. This requirement limited care for many folks requiring 60+ minutes of care coordination where they may not be a ‘substantial care plan revision’ as defined by CMS. To prevent overuse, Medicare is keeping the “moderate or complex medical decision making” point in place.

3. Remote Physiologic Monitoring (RPM) would allow remote care managers

Remote Physiologic Monitoring (~$60-$120 per patient per month for monitoring+managing Blood Pressure/Blood Sugar and other vitals readings remotely) has been affected in 2 key ways. First, there’s a new add-on code (994X0, 0.5 RVUs) for an additional 20 minutes of clinical care management time relating to vitals monitoring, on top of the existing CPT99457 code for the first 20 minutes.

Second, the proposal puts both CPT99457 and this new add-on code under general supervision rather than direct supervision. This means that off-site care managers like CircleLink’s 100% RNs can provide the “Remote physiologic monitoring treatment management services”, whereas in 2019 the clinical staff providing services needs to be on-site in the same facility as the supervising provider/doctor.

4. New “Personalized Care Management” for patients with 1 ‘serious chronic condition’

Finally, a new “Personalized Care Management” code – GPPP2 – covers patients with a single serious chronic condition. This opens up PCM for those who don’t qualify for CCM’s stringent 2-condition requirement. However, it should be noted that this code requires 30 minutes of staff time while paying the same amount as CCM pays for 20 minutes.

GPPP2 will require 1 condition for which a patient has received care for 3-12 months, which puts patient at risk for hospitalization, or has resulted in a recent hospitalization. Insofar as we can say now, GPPP2 may be billed by a specialist in parallel with a Primary Care Provider doing CCM. Terms and payment amounts will be roughly the same as CCM (~$42 per patient per month), except that the proposed 2020 fees appear to require 30 minutes of clinical staff time instead of 20 minutes for CCM.


Is your practice prepared to take advantage of these adjustments to CCM, RPM and other care management programs? Are you already doing your best with existing CCM and BHI programs? CircleLink can help demystify the reimbursement process and assess whether your practice is a fit for increasing revenue and patient health through these reimbursable services.

To learn more, please drop us a line at or call 917-999-6560.

CircleLink Partners with Newark Beth Israel to Expand Chronic Care Management

CircleLink Health, a leading preventative care platform, is delighted to partner with Newark Beth Israel (NBI), a RWJBarnabas Health facility, to provide Chronic Care Management and other preventative services to thousands of Medicare patients.

By transitioning to CircleLink’s best-in-class Chronic Care Management and Behavioral Health platform, NBI has significantly expanded their in-house program with zero additional staff, while leveraging CircleLink’s 100% RN care coaches to improve chronic condition outcomes. To date, the partnership increased patients serviced over 20X since launch in late January 2019. Furthermore, from February to June 2019, the program retained over 99% of patients who met billing requirements for 3 or more months.

Raphael Anstey, CircleLink’s CEO remarked: “We couldn’t be happier with the initial roll-out at Newark Beth Israel. The team there is singularly focused on patient outcomes and experience while helping us scale operations.” He went on to say “We’re also evaluating other preventative care opportunities in areas where the NBI team has expressed interest, both at NBI and at the greater RWJBarnabas system.”

Interested in how CircleLink’s preventative care platform can increase patient health and practice revenue at your facility? Drop us a line at!

About CircleLink

CircleLink Health offers telephone nursing for Chronic Care Management (CCM) and Behavioral Health Integration (BHI), as well as tools to boost Annual Wellness Visits (AWV). This allows providers to improve health and earn new Medicare payments (up to $100K+/year per doctor). CircleLink makes it easy by handling patient targeting, enrollment, and integration with various EHRs so doctors can stay on one system. CircleLink uses 100% registered nurses for meaningful remote patient engagement on doctors’ behalf.

About Newark Beth Israel

Founded in 1901, Newark Beth Israel Medical Center (NBIMC) is a regional care teaching hospital that provides comprehensive health care.  NBIMC also offers many preventive health programs that promote wellness in the community, including The Beth Greenhouse, which provides access to fresh produce and health and wellness education to local residents. Community wellness initiatives include the award‐winning Beth Greenhouse, KidsFit Program, and The Beth Challenge, as well as the Rev. Dr. Ronald B. Christian Community Health and Wellness Center.


Haziq Ghani
CircleLink Health
(917) 746-2708

Dr. Survey: What’s stopping Chronic Care Management and other programs


In 2015, Medicare launched Chronic Care Management (CCM), a program incentivizing practices to follow up with chronic condition patients outside the office between visits. Other programs followed to improve health, like Behavioral Health Integration (BHI), which focuses on follow-up between visits for patients with mental conditions. These programs provide a significant financial incentives to providers, up to ~$42-$80 per  patient per month, or up to $200K+ per provider annually. 

However, despite these programs’ health improvements and systemic cost savings, many doctors and their staff lack the infrastructure and extra staff to implement them.

CircleLink Health conducted a survey of 51 primary care providers and 9 cardiologists to determine their general level of CCM awareness and preparedness. The results suggest that while physicians believe their practices could benefit from CCM/BHI, they struggle to implement these programs effectively. In fact, despite 77% of physicians polled being aware of Chronic Care Management’s launch in 2015, only 12% reported they are billing for CCM consistently.

The Challenges of Treating Patients with Chronic Conditions:

Patients with chronic illnesses can be time-consuming for practices. For instance, follow-up calls that can ensure these patients take their medication and understand their doctors’ instructions take hours per week. Specifically, our poll showed most doctors’ staff spending between 8-20 hours per week on such follow-ups. (62% reported their staff spent 8+ hours each week on such calls.)

Medicare Chronic Condition Chart

Even with the above time being spent on follow-ups, only 7% of physicians polled reported their staff always having more than enough time to call their chronic condition patients in between appointments. 

Which makes sense: Office staff are crucial to the day-to-day operations of practices. Spending hours on the phone with these chronic conditions patients can disrupt their workflow. Having new resources funded by CCM or other preventative programs can free up staff to focus on patients who need attention in-office, among other priorities.

The Challenges of Implementing CCM Programs:

Although preventative care programs like CCM seem to be a perfect solution to these challenges, our survey found that physicians struggle with finding the needed staff time, resources and infrastructure.

Per the below chart, the three most cited barriers are (among the 65% of respondents who hadn’t launched):

  • Lack of staff time required for new revenue programs
  • Difficulty in understanding complex program requirements
  • Unfamiliarity with these programs’ reimbursements

Barriers to implementing Medicare preventative health programs chart

In addition, finding time to research how to implement a CCM program can be difficult for physicians and staff who fill their entire workdays with clinical matters. The complex regulatory environment and resulting operational needs surrounding these programs/reimbursements makes this work time consuming. 

CircleLink Health Can Help Your Practice Implement a CCM/BHI Program:

Luckily, CircleLink Health provides the technology, telephone RNs and guidance physicians need to implement successful preventive care programs with zero additional staff or upfront costs. From full-service CCM/BHI solutions to customized/targeted offerings based on practices’ needs, CircleLink can help. Interested in learning more? Send an email to

Are Your Care Coaches Earning Patient Trust Over the Phone? (Why and How-to)

Telehealth is an area of growing importance in healthcare as it enables convenient patient care and follow-up at lower costs than the status quo health facility, especially for patients who live in rural areas or need follow-up between visits to manage chronic conditions. In these cases, receiving care over the phone from a qualified professional can be enormously beneficial. 

CircleLink is part of this change, with best-in-class tele-nurses who serve thousands of patients with chronic or behavioral issues each month. The work that these registered nurses do to support patients between doctors’ visits significantly improves revenues, and has been shown to reduce costs through better health outcomes

However, there is a challenge for telehealth.  Patients don’t have the same face-to-face contact with healthcare professionals. Apart from prescribed treatments, the psychological support received from direct interactions with healthcare professionals is a powerful force in fostering speedy recovery and peace of mind among patients. Conveying this psychological support over the phone, however, is more difficult than doing so in person. The key to making remote care effective is for healthcare professionals to earn the trust of these patients whom they may never meet.

Why trust matters

Building trust in a telehealth relationship is important for three reasons: First, for clinics and hospitals, trust is key to retention in chronic care management or behavioral health integration programs. Adherence has been shown to be 2.5 times higher in patients who have high levels of trust in their doctor than in those with low levels of trust (adherence rates of 43.1% and 17.5% respectively). Patients who adhere are more likely to stay with the program, meaning better revenue for the clinic or hospital.

Second, trust leads to better healthcare outcomes for the patients. The patient-clinician relationship has been shown to affect health outcomes that are both objective (such as blood pressure) and subjective (such as pain scores). A trusting relationship is not only important for making the patient feel good, but also for their physical well-being and recovery.

Finally, patients are more likely to stick with their clinician when they receive consistently outstanding service.  Feedback from CircleLink’s registered nurses illustrates this relationship vividly: 

“I spoke with our patient today, and she was very grateful for our program, says that she got a call from his [practice] office [after Circlelink RN coordinated], an appointment was set up and she is feeling much better. Says she never would have gotten in so quickly without our [CircleLink’s] call.” – Suzanne, registered nurse. 

“The patient was very happy because after 1 1/2 weeks of trying to get a script for a glucose meter, after my call to her they resolved it within a few hours [due to CircleLink RN following up with practice]. She was also appreciative of my follow up call.” – Lisa, registered nurse.

How to build trust: The Basics

Building trust requires investing in time and practice, but it’s well worthwhile. We at CircleLink have found techniques that enable new tele-nurses to adapt their existing expertise and patient experience to telephone care quickly. We’re delighted to share some of those insights below.

Right at the start of a call, it is important for the tele-nurse to introduce themselves and mention that they are calling on behalf of the patient’s specific doctor straight away. They may also mention the name of the patient’s practice. This will let the patient know that they can trust the caller, and, will make them feel more at ease. 

Next, the caller should explain that the patient’s doctor endorses the chronic care management program, and that the call was set up by the doctor in order to keep in touch between appointments. This helps the patient understand the relationship between the telehealth services on offer and the physician’s regimen that they are already familiar with. 

Once it has been established that their trusted doctor supports the patient using the telehealth service, a more in-depth conversation can begin. In the experience of our nurses, discussing medication is a productive first step, as it builds credibility with the patient. For example, the patient may wish to discuss how to manage their medication regimen, or to list any side effects they might be experiencing. By focusing conversation on these important details, it demonstrates that the telehealth nurse is a trained medical profession who understands the patient’s specific care needs.

Finally, taking the time to listen to the patient cannot be stressed enough in trust building. In our experience, allowing some silence into the conversation invites the patient to ask questions or to bring up issues that are concerning them. This is important in making the patient feel comfortable sharing more key health and lifestyle information, and to having them involved in their care. 

More Advanced Tips from CircleLink’s Tele-nurses

In addition to these basic trust-building techniques, CircleLink’s qualified tele-nurses have their own tips to share on building trust:

“First and foremost, smile and be enthusiastic about the program, the practice and the patient. You can hear a smile over the phone,” says Lisa B. RN “Get personal, and make reminders in your notes so you can refer back to spouses and names of family they live with, pets’ names, etc.” 

LeAnna, another registered nurse at CircleLink, likes to ask open ended questions like “How have you been feeling?” or “What is new with you since we spoke last?” in order to give patients space to open up that isn’t dictated by a script. She also emphasizes the importance of learning the patient’s preferred name and their preferred times to speak on the phone for their convenience.

Both LeAnna and Lisa stress the importance of being reliable and showing up to phone appointments as promised. In addition, it helps to remember that elderly people can be wary of phone scams, so LeAnna encourages the patient to call the doctor’s office and confirm her identity if they feel unsure. “I’ve found that when I do that, the next call with the patient goes extremely well, and they are appreciative of our understanding their need to get that reassurance that we are who we say we are,” she explains.

The nurses’ experiences confirm what the research has shown too: that making the patient feel heard is vital. “Listening to the patient and validating that they are being heard is important,” says LeAnna. “I want every patient to know that they have my full attention, and I care about what they are saying.”

In conclusion

Building trust with patients is key to successful telehealth programs. Both the scientific evidence and our nurses’ clinical experience backs this up. For more information about telehealth and how it can benefit both health providers and patients, requests a 1-on-1 free consultation here.

What’s My Reimbursement and Profits for CCM?

A chronic care management (CCM) or behavioral health integration (BHI) program has great potential benefits for patients, but requires considerable investment of resources and administration across a large number of staff. These hurdles have contributed to the 2-3% adoption rate of CCM in the 1st two years of the program*. On the BHI side, a brief from the Institute for Clinical and Economic Review (ICER) showed that BHI is more effective at promoting improved health outcomes than traditional care, but costs between $20 to $3,900 per patient depending on location and individual patient needs.

The good news is that the extra revenue that a practice receives from BHI/CCM programs, which is roughly $40-80 per patient per month, can offer significant profits and ROI, if managed properly. This is where the benefit of prior CCM/BHI experience comes in.

There’s also additional program value in terms of health, quality of life and savings to Medicare.  For example, a report by Mathematica from 2017 found that CCM services (for the sample studied vs. a control group) reduced net Medicare costs by over $30M.

So if it makes sense for your institution to offer a CCM / BHI program, should you run it yourself, or should it be outsourced? Today we’ll help you make this decision by walking you through the reimbursement and profitability of CCM and BHI programs.

Data on reimbursements

The reimbursement for CCM varies considerably between states, ranging from $39 to $57 per patient per month. The feasibility of administering a cost-effective CCM / BHI program therefore changes depending on the cost, effectiveness and efficiency of overheads. Wondering what your reimbursement is?  Drop us a line at for access to our comprehensive region by region reimbursement data set.


Profitability drivers and example calculation

1. Staffing

Firstly (and most importantly, given high staffing costs associated with care) is the fixed overhead costs or vendor costs for staffing relative to the rate of reimbursement. CCM/BHI requires co-ordination and management of a team, including roles such as primary care physician and care manager.

When considering staffing costs, also take into account all of the staffing hours that are required on top of the 20-40+ minutes per patient per month of direct patient contact. This includes time for issues like determining patient eligibility, enrolling patients (and documenting enrollment), preparing care plans, tracking approval of those plans by a doctor, and presenting care plans to patients. There will also be considerable time for non-call time activities like scheduling calls, documenting calls, managing/training care coaches, and trying to contact unresponsive patients. Finally, there are also time costs in determining which patients can be billed for and preparing their billing information, as well as the usual staffing costs of vacation and sick days.

In terms of BHI programs specifically, behavioral health specialists are an important group to consider, as they may need to be hired from outside the usual streams of staff acquisition. Depending on patient needs, behavioral health specialists could come from a range of backgrounds with different associated levels of cost including social work, nursing, psychiatry, psychology, substance abuse support, or counseling. As with other programs, the costs for staffing will vary depending on region, and also on whether these staff are permanently employed or are agency workers.

2. Number of patients enrolled and their duration on program

A second key consideration in terms of profitability is the reimbursement, driven by i) duration of the program for each patient, ii) the number of patients enrolled and iii) the number of enrolled patients reached each month. As mentioned in the introduction, a CCM/BHI program can be expensive to set up without outside help. To offset this initial expense and the ongoing fixed costs of an in-house program, practices must soberly estimate if they have the HR and technology to efficiently execute on each of parts i), ii) and iii) above.

A typical CCM patient, as described in the Mathematica report, receives services for between four and ten months. In the case of practices using CircleLink to avoid such fixed cost risk, patients are typically on the CCM/BHI program for somewhere in the range of eight to twelve months and 90% of active, reachable patients may be billed each month, as they are given care by high level staff like registered nurses. CircleLink has found that using higher level registered nurses keeps patients on the program longer, vs. using medical assistants.

3. Total profitability

The total profitability of the program can be calculated relatively simply: consider the patient-months billed times the reimbursement rate, then subtract total costs such as staffing costs, employment taxes, real estate and facility management costs, and the overhead costs of the team doing care coaching.

For example, consider a Licensed Practical Nurse working on a CCM program operating in New York. The staffing costs of such a position are around $58,000 per year, or around $70,000 in total including overhead costs and taxes. With a NYC reimbursement rate of $49 per month, as shown in our reimbursement table, you can see that the nurse in question would need for bill for 120 patients per month just to break even.

When you consider all of the staff work required in addition to the care coaching call time, plus the LPN being pulled into non-coaching facility duties, this level of billing may not be feasible. Achieving a higher level of patient billing for a return on investment may be even further afield.

CircleLink can help

If you are looking for support in the management of your own CCM / BHI program, then CircleLink can help. Our services have zero upfront costs, can launch in 2-4 weeks and are always profitable (you only pay fees for billable patients). Care coaching is handled by our team of 100% registered nurses so you needn’t worry about hiring, training, or scheduling staff to follow up with patients between visits. And we offer a dedicated expert account manager to walk you through the process and answer any questions. Our service is trusted by both large health system practices and smaller clinics nationwide. Call us today at 917-999-6560 to request a demonstration and learn how we can help you offer the best care to your patients.

*for 2015-2016, according to CMS’s 2017 Physician Fee Schedule and assuming ~70% of Medicare beneficiaries have the 2+ chronic conditions needed for eligibility

Interview with care coach LeAnna R., RN


Care Coaches are the key to Medicare’s Chronic Care Management (CCM) and Behavioral Health Integration programs, providing the non-face-to-face follow-ups and coaching to manage chronic/mental conditions when they matter, between regular office visits.  At CircleLink, we use 100% RNs with over 10 years of experience and focus on providing a best-in-class experience to these key partners. Care coaches are the true stars of CircleLink’s platform.

In that vein, today we’re showcasing what it’s like to be a CCM Care Coach in the words of one of our top care coach partners, LeAnna R., RN.

A day in the life of a CCM nurse

I have to start by telling you that a day spent on the job as an RN Care Coach is wonderful. Switching to this job has been a rewarding and welcome change for my family and myself. I don’t have to commute or travel every day; I don’t even have to go outside if the weather’s bad. I can stay home with my family and cats, one of whom is 16 years old and needs me home throughout the day.

One of the best things about this job is flexibility. I have a set amount of hours that I work each day. Once I’m ready to start my work day, I log in and let my Director of Operations and Community Manager know I’m ready.

The first thing I do is check my callback tracker to see if any patients called while I was away. I start by calling those patients first. Following that I start on my scheduled activities calling whoever’s most appropriate first based on my patient’s preferred call times.

The calls themselves are diverse and include people from all lifestyles. Some patients live alone, love to talk, and look forward to their call each month. I come to know not only their health concerns, but also about their family, pets, financial struggles, and community concerns. Other patients are busy and don’t have much to say when I call. However, they still appreciate knowing they’ll be checked in on each month and that we’re here if they need something.

After talking to the patient and making recommendations based on their care plan and current health, I note the patient’s progress and I forward that note and/or call the practice, if necessary. Once finished with the patient’s progress note I schedule his or her next call and proceed to call another patient.

I keep working until I run out of calls or finish my list, whichever comes first. I then message my Director of Operations and check out for the day. 

How I became a care coach 

I started my nursing career as a Registered Nurse in 2008, working in the ICU. That was an incredible learning experience that helped me become the nurse I am today.

Specifically, it helped foster my passion for teaching patients about lifestyle choices that can help them. I realized that many of our ICU patients’ problems were preventable by better life decisions, and I wanted to make a difference in that area.

After leaving the ICU I worked in Telemetry for a few months and saw many of the same issues there too. This eventually led me towards a nursing job in the Wellness and Preventative Medicine industry. In this position, I traveled to organizations and corporations to provide onsite wellness screenings and vaccinations for employees.

Doing this for a few years, I was able to see patients making lifestyle changes because of the results and coaching they got from our screenings. The excitement they had when telling me about the weight they had lost, the change in how they felt, and their lower risk for health complications was incredibly rewarding.

While I loved my work in the Wellness industry, I was tired of traveling and began looking for other options that would have me home more. That’s how I ended up at CircleLink Health.

To date, this has been my favorite job. It lets me use my nursing knowledge, communication skills, and love of helping people — all without having to leave the comfort of my home.

A particularly memorable case 

One time, I was making a first-time call to a patient. When she answered, she was out of breath and sounded very scared. She couldn’t catch her breath and hadn’t dialed 911 for assistance, so I called emergency services on her behalf.

While we were waiting for them to arrive, I talked to my patient and helped her stay calm. When I called her the next month, she was very appreciative and said she didn’t know what would have happened if I hadn’t called her that day.

Most positive impact on patient health 

I was once on call with a male patient and asked if he had any health concerns. As he was describing his symptoms, I got an eerie feeling that all of them were consistent with Congestive Heart Failure.

Although the patient felt seeing his doctor would be a bother, since the last check-up had happened just 2 months prior, I ended up calling his doctor’s office and speaking with a nurse. We were able to collaborate to get the patient to the office within an hour, and evaluated him before transferring him to a hospital for CHF treatment.

The patient’s spouse later said she was scared to think about what would have happened if I hadn’t called them that day and she expressed gratitude for the service.

With new medication and a better understanding of the patient’s dietary restrictions, they were able to improve his condition. That was very rewarding for me.

Most challenging practice

The most challenging practice is one that isn’t making full use of our service. For example, a practice that only wants to receive notes from nurses in emergencies is, in my opinion, missing out on many of the benefits of the CCM program. Also if the practice does not allow me as an RN Care Coach the ability to speak with or leave a message with the provider’s nurse this presents a challenge as well.

Biggest remote care coaching challenge

My biggest challenge would have to be getting patients to understand the service we provide and trust what I do and who I am. Getting the program details across isn’t always easy, but I have noticed that two things help.

First, I encourage patients to ask questions and I provide them simple, precise answers. Second, practices that proactively notify patients about what’s going to happen beforehand can help a great deal.

Sometimes, patients are very skeptical and do not want to speak with me regarding any of their information until they have spoken with their provider. I welcome this concern and encourage patients to verify the information I provide before we proceed with further calls. I have found that by acknowledging patient’s feelings and allowing them the chance to have their concerns addressed a solid foundation for a trusting nurse/patient relationship is developed.

– LeAnna R., RN

If you’d like to learn more about CCM or see how we can help, great! We’re here for you. Please email or call (917) 746-2708.