Chronic Care Management (CCM) is a proactive, validated, preventative care service developed by Medicare for patients with two or more chronic conditions. CCM’s goal is to expand access to care, improve patient outcomes, and reduce the cost associated with overall patient care delivery. Patients with Medicare, Medicare Advantage, and replacement plans are eligible for this service, and many commercial payers also support reimbursement of the program.

CCM is delivered to the patient by certified clinical support staff over the phone for episodes of 20 and 60 minutes on average per month. Each patient requires a care plan with goals and objectives to address their condition set, engaging the patient and their provider to take a proactive approach to health and wellness between their typical office visits. Cosán excels at care coordination and promoting patient engagement in their care plans.

Cosán’s Principal Care Management (PCM) program allows specialist providers to deliver most of the values of Chronic Care Management (CCM) to their patients. Like CCM, the PCM program is also a transformative care service for patients with chronic conditions, but specifically targeted to patients with a single high-risk or complex chronic condition, which is under the management of the patient’s specialist.

As PCM is more focused, it benefits from 30-minute intervals of care (as opposed to CCM’s 20-minute intervals). PCM aims to address each patient’s specific chronic condition in the most effective way, stabilizing it to prevent complications or new diagnoses from arising and improving the patient’s overall health prognosis. PCM is also not competitive with a primary physician’s delivery of CCM services; patients may benefit from both at the same time.

Up to 75% of primary care visits include mental or behavioral health components, and these behavioral health factors have a major influence on morbidity and mortality. Cosán’s Behavioral Health Integration and Monitoring (BHI/BHM) is unique in that we regularly deliver a unique set of stepped screenings to the entire patient population enrolled in care management services to identify a wide range of issues for early intervention. While typical programs simply cover depression and anxiety, Cosán extends this coverage to additional behavioral, mental and social conditions negatively affecting patient outcomes.

Remote Patient Monitoring is the use of technology that allows for the collection of patient data outside of a Providers office or hospital to monitor a patient’s health and make more informed medical decisions. Cosan aligns our Remote Patient Monitoring (RPM) service with our condition-specific Clinical Pathways (CPWs) for each patient to track the progression and management of illness against condition-specific protocols to support improved outcomes.

As value-based care models continue to expand in an increasingly complex health care system, Cosán has developed targeted supplementary service offerings which provide additional support for population health management, improved outcomes, quality scores and financial costs. These programs help extend the reach of our client provider’s into the patient’s home.

Population Health Analytics – Population health and outcome-based reporting on Cosán care coordination enrollees provides a more robust set of analytics and reporting including identifying and addressing social determinants, identifying behavioral issues and promoting healthy behaviors, preventing additional chronic disease progression by helping to identify patients that may be shifting to high-risk status, and addressing care gaps with monthly proactive outreach.

Hierarchical Condition Category Scoring – HCC coding helps estimate future health care costs for patients. Cosán has a unique approach to efficiently code enrolled patients through a short process which identifies gaps in the ICD-10 diagnoses documented in the EHR chart. Using multi-sourced risk adjustment data and conditions verified directly with the patient, client practices are able to correct gaps in their RAF score to assisting in the development of programs for population health management to improve outcomes and achieve higher reimbursement.

Health Risk Assessments for Medicare’s Annual Wellness Visit – Cosán’s  preventative care module is focused around a comprehensive health risk assessment to support compliant delivery of annual wellness visits (AWVs). Coupled with a direct integration to Medicare’s eligibility and claims transaction platform, Cosán identifies open gaps in care and a broad range of health risk factors, including medications, lifestyle choices, and mental health.

Social Determinants of Health (SDOH) Support – SDOH covers a wide range of social and economic issues which often negatively affect a patient’s health. Cosán has developed a comprehensive program which efficiently identifies SDOH issues and coordinates patient needs with federal, state and local assistance programs to improve conditions.

Medication Management – Cosán has partnered with a leading national organization to deliver a comprehensive medication management and pharmacy care solution for patients who have chronic conditions, take multiple prescription medications, and receive care from multiple providers. For patients, the program is an easier way to manage daily medications, receive clinical support for a safer medication regimen, and ensure regular coordination with the larger healthcare team. Providers benefit from support for more complete and accurate medication profiles, collaboration to address possible medication risks, and more efficient refill management. 

Dietary and Lifestyle Support – Cosán has partnered to deliver ancillary care treatment around nutrition, fitness and behavior modification. The program is tailored to meet the condition-specific needs of patients in the areas of weight loss procedures, gestational diabetes and metabolic issues, oncology, digestive diseases, cardiac rehabilitation, preventive medicine, and general wellness. The model is focused on live telephonic or video support with nutritionists, and access to nutritional information and tools – including fitness classes – from anywhere. 

Remote Therapeutic Monitoring (RTM) – RTM uses technology to remotely deliver therapeutic episodes of care to patients and track progress between regularly scheduled visits. Cosán’s RTM program extends many areas of physical and occupational therapy (PT/OT) care delivery into the patient’s home, either replacing or supplementing in-office or facility delivery. For providers, Cosán removes the considerable learning curve of delivering RTM through a turn-key solution, which is focused in rehabilitation therapy for improving outcomes, collecting better data, and increasing revenue.