HubChart™ CCM

HubChart™ CCM app is HIPAA compliant patient centered collaborative care group messaging app. It main use is for the easy implementation of Medicare’s Chronic Care Management (CCM). The patient centric group chat, called PCX (Patient Collaboration Exchange), is an easy and efficient way for the health care team to quickly receive, share, coordinate and record valuable patient info. The easy-to-use patient and healthcare provider interface makes it easy for them to join in the care collaboration.

USES OF HubChart™ FOR HEALTHCARE:
The only mobile tool for Medicare’s Chronic Care Management program
Patient Centered Group Collaborative care
Care coordination between clinicians, pharmacy, lab, radiology, patients and patients relatives.
Complex case management
Transition of Care management
Risk Management and Risk Stratification

USES FOR CONSUMERS/PATIENTS:
DIY electronic health records
Patient empowered Care Coordination

What is CCM?
 Chronic Care Management (CCM) is a non face-to-face healthcare service provided to medicare beneficiaries who have multiple chronic illness. In chronically ill patients, early signs of worsening chronic condition occurs unpredictably and happens in between office visits. Before CCM, all physician reimbursements are all encounter based. This means that doctors were not reimbursed for non face to face work such as calling patients, coordinating with specialist, messaging and other care collaboration. Now, this same work done by staff same work that staff have been doing all along but never got paid are now billable through the CCM program.
Often, the once a month face to face encounters doesn't capture the fluctuations of signs and symptoms of the patient's illness. The analogy is like a snapshot picture of a 2 hour movie doesnt tell you the whole story.
The goal of CCM is to provide focused care by providing a roadmap of the plan of care (CCM care plan) based on the patient's chronic disease, risk stratification and measurable treatment goals. The practice should be able to provide ongoing care by means of more open communication, easier access to care and better collaboration by healthcare team members, patients and family to prevent acute exacerbation/decompensation of a chronic medical condition, or functional decline.
of today's “by appointment only” scheduling prevent early intervention by . Also, theThe program pays practices for non face to face care time spent by staff under the physician's supervision. For practices to deviate outside of their routine volume based encounters and adapt CCM is not an easy task. Its always a question of where and how to start

Why HubChart™ is perfect for CCM?
HubChart™ CCM makes it easy to maintain and share care plans, manage transitions of care , case management, and coordinating and sharing patient health information timely within and outside the practice anytime.
Unlike EHR, the instant messaging function of HubChart™ CCM make it a very efficient tool for real time care collaboration. And unlike other group chat apps, the group members on HubChart™ CCM ccm require the identity verification and are restricted to care team members only. The group members can be added by invitation only and are managed and controlled by group owner and group admins. The PCX group is a patient named group and the conversation of the group members are centered around the care and well being of the patient. The patient centered groups are problem focused and the responses are highly specific and solution driven.


Feature summary:
New:
Capability of forwarding work billable for CCM form PCX group chats to the CCM module.
Easily Record and keep structured CCM time logs for staff and supervising clinician with ability to track total billable CCM time