Case Study: Northern Ohio Medical Specialists achieves improved chronic care management and reduced hospitalizations with eClinicalWorks Chronic Care Management

Building a Team for Chronic Care Management

Northern Ohio Medical Specialists (NOMS) is a 120-provider, multi-specialty group serving patients across six largely rural counties in Northern Ohio. Faced with a growing population of older adults with multiple chronic conditions, NOMS struggled to provide intensive, continuous care while documenting non–face-to-face work and adapting to new CMS reimbursement models; providers and patients were initially skeptical and the practice needed a scalable way to improve outreach, quantify time spent, and capture value.

NOMS implemented eClinicalWorks’ Chronic Care Management (CCM) solution in 2016, building an 18-person team of care providers and case managers and using the CCM dashboard and timer to track work and coordinate care. In two years they enrolled more than 860 of ~16,000 eligible patients, improved care coordination and preventive screening (including early cancer detection), reduced hospitalizations, increased physician satisfaction by removing bottlenecks, and began capturing reimbursement for previously unquantified non–face-to-face services.

Northern Ohio Medical Specialists

Rebecca Rohrbach

Doctor of Nursing Practice, Vice President of Population Health