Chronic care managment platform improved patient access to timely and quality care


Healthcare, Chronic care management


NodeJS, Angular, TypeScript,REST ,SOAP,Web Services

Client Requirements

The client was in the U.S.-based, a leader in interactive health management and remote patient monitoring technology . The healthcare organization provides primary care services to a diverse population of patients.

The organization has identified a need to improve the management of chronic conditions among its patients. Many of their patients have multiple chronic conditions. These patients have difficulty managing care for conditions such as asthma, diabetes, COPD, cardiovascular disease, obesity, and general wellness.

Thinkitive Solution

Thinkitive's business analysts and subject matter experts took multiple calls with clients and understood requirements. They created low-fidelity wireframes that were fit for customer requirements. After reviewing the wireframe, the client made some minor corrections and created a high-fidelity wireframe.

We assigned a team to work on the CCM program. They will build microservices for each module. This architecture uses a microservices-based approach.

We designed three platforms Admin, Provider & Patient. Value-added features include:

  • Patient onboarding

  • Checking patient eligibility

  • Device management

  • Creating a patient-centric care plan

  • Alerts & notifications

  • Alerts & notifications

  • Tasks

  • Messaging

  • Video calls

  • Sessions

  • Automated time tracking

Custom solutions added valuable functionality to provider-patient communications, streamlined workflow, decreased provider overloads significantly, and optimized costs.

The key features included

  • Customizable Dashboard

  • Personalized care plan for each patient

  • Assign Care Team Members

  • Disease-specific questionnaire for common chronic diseases

  • Two-way communication with patients through Text Messages, Audio & Video Calls

  • Monitor Patient 24*7

  • Synchronization of patient self-assessment data from Mobile app

  • Alert & notification

  • Automated Time Tracker & Monthly billing report

key features of chronic care management application

Solution Highlights

  • Identify Eligible Patients for CCM & Enrollment

    The provider can view a list of eligible patients with at least two chronic conditions. A provider can send CCM program invitations to those patients. Providers can pull patients' information from the EHR or enter it manually.

    The patient must accept the program invitation before the provider can start the process. This includes a face-to-face interview and assessment of the patient's details, conditions, allergies, medications, and expected outcomes. During enrollment, the provider can identify patients' complex or non-complex conditions as per American Academy of Family Physicians (AAFP) guidelines.

  • Care Plan Development & tracking

    The provider can develop care plans for the patient based on their conditions and goals. The care plan included patients' conditions, barriers, interventions, medications, activities, vitals, and goals to be achieved. Assign care team included primary care providers, care coordinators, healthcare trainers, and behavioral health specialists.

  • Partners & Sessions

    We provided a partner module for the client. This partner could be a dietitian, Yoga trainer, nutritionist, meditation, physiotherapist, etc. They could take sessions with patients and provide value-added services and education to patients. Patients have access to schedule or reschedule sessions at their convenience.

  • Care Plan Review

    A patient's health information, care plan development and plan goals can all be reviewed by providers. Based on this review, they can determine how well the patient is doing. The care plan can also be updated if necessary.

    It can track how much time each clinician spends with each patient while analyzing patient data.

  • Patient engagement

    Top priorities were delivering robust patient communication software and developing interactive modules with cutting-edge capabilities.

    Patient mobile application: The CCM patient mobile app contains multiple features. These features help patients to better control their condition and stay connected with their healthcare providers. The patient can track their vitals, symptoms, and medications, set reminders for when to take them, and request prescription refills.

    Patient commnunication: The service offers constant assistance to patients through text, audio, or video chat. The messages can be submitted at any convenient moment and are secured as per the the HIPAA compliant parameters. Providers can respond to them quickly and avoid wasting time on unnecessary phone calls. As a result, our providers and their patients may communicate at the best time of day.

    Patient Education: The provider can upload any material to improve the patient’s condition and assign that material to the respective patient. Patients can access educational resources, such as videos and articles, to learn more about their conditions and how to manage them.

  • EHR & Device integration bridge

    We have developed a specialized EHR bridge. It can connect to any EHR via EHR providers. This bridge can identify patients who are eligible for a Chronic care management program.

    The Device bridge helps the patient to integrate multiple devices. This enables them to track their health data such as weight, activity levels, blood pressure, heart rate, and blood sugar levels.

  • Advanced Tasks management

    The provider can consolidate all tasks as per the patient. The provider can segregate priority-wise in the high, moderate, or routine apps as per patient severity. Patient's tasks include reviewing comprehensive care plans, updating medication updation, providing education, coordinating with other providers, documentation & reporting.

  • Automated time tracking

    The automated timer will run as a provider interacts with a patient by reviewing the care plan, communicating, providing education, etc. This system can help providers meet CCM service requirements and accurate billing for their time.

  • Billing

    This CCM platform keeps track of all calls and interactions, bills for them, and creates straightforward billing summaries. The CPT code can be automatically assigned per Central Medicare and Medicaid Services (CMS) guidelines. The provider can review, download and send the reports to the payer for reimbursement.

  • Customizable Dashboard

    The interactive dashboard tracks and monitors crucial healthcare metrics in one place. Users can delve deeper into the data and make well-informed, data-driven business decisions using various interactive features.

Value Delivered

  • Increase Revenue.

  • This platform help providers and practices save time, improve outcomes, and increase earnings.

  • Quickly Identify, enroll, and provide value-added services to patient

  • Discuss care plans with other providers and care teams.

  • Patients and providers can text or call their friends, family, and care team from the platform.

  • Improve patient outcomes.

  • Customized EHR middleware is a bridge and can instantly integrate with any EHR.