CCM Call Month Workflow SOP

PURPOSE: Guide staff through a complete, compliant, and billable Call Month — covering pre-call preparation, the live patient call, and all post-call documentation. A well-executed call month generates 35–55 billable minutes and sets the foundation for a smooth off month

Phase 1 — Pre-Call Preparation (7–11 min)

⚠️ Compliance Note: Billable: Pre-call prep, the live call, and all post-call documentation ALL count toward the monthly 20-minute CCM billing threshold. Timestamp every phase. A fully documented call month can yield 35–55 billable minutes.

⚠️ The Compliance Team conducts periodic reviews to ensure all patients receive appropriate care. We ask all staff to uphold the highest standard of integrity in documenting every activity accurately and completely—to avoid immediate termination.

⚠️Document every interaction as if it will be reviewed by an auditor, attorney, or accreditation body — clear, complete, and timestamped.

  • Open the patient's CCM record before dialing. Review the care plan, last call notes, recent labs, active medications, specialist notes, and upcoming appointments. Note any changes or new concerns to address during the call. Timestamp start and end—and DOCUMENT.

    Timestamp: 5–8 min

  • Check quality measures and flag any overdue screenings, labs, immunizations, or referrals. Add flagged items to your call agenda so nothing is missed during the conversation.

    Timestamp: 2–3 min

Phase 2 — The Live Call (18–28 min)

  • Introduce yourself and your role. Ask how the patient has been feeling overall since the last contact. Allow them to share freely before moving to the agenda. This builds trust and often surfaces issues not documented in the chart.

    Timestamp: 3–5 min

  • Go through current medications one by one. Ask: Are you taking them as prescribed? Any side effects? Any trouble affording them? Document discrepancies, refill needs, or concerns to flag for the provider after the call.

    Timestamp: 3–5 min

  • Review active care plan goals with the patient. Assess progress on each goal. Update goals based on patient feedback and current health status. Confirm the patient understands their plan and agrees with any changes. Document updates in real time.

    Timestamp: 5–7 min

  • Confirm all upcoming appointments. Identify any specialists or follow-ups needed. Offer to assist with scheduling or transportation if barriers exist. Document any referrals placed or appointments confirmed during the call.

    Timestamp: 2–3 min

  • Ask about barriers to care: transportation, finances, caregiver stress, food access, housing stability. Connect to community resources as needed. Document all social determinants of health (SDOH) identified with specific details.

    Timestamp: 3–5 min

  • Summarize key points from the call. Confirm the next call month and remind the patient they can reach out anytime via portal or phone. Ask if they have final questions. End on a warm, supportive note. Note any agreed-upon action items.

    Timestamp: 2–3 min

Phase 3 — Post-Call Documentation (11–17 min)

  • Immediately after the call, complete full notes in the CCM activity log. Include all topics discussed, patient responses, care plan changes, referrals placed, and follow-up items. Timestamp start and end of documentation separately from the call time.

    Timestamp: 5–7 min

  • Formally update the care plan in the system based on call findings. Update goals, medications, provider notes, and any SDOH flags as appropriate. Timestamp this activity separately from call notes.

    Timestamp: 3–5 min

  • Act on any immediate follow-up items: send referrals, contact pharmacy, message the provider about new concerns, or send the patient a portal summary of the call. Document each action with its own start and end timestamp.

    Timestamp: 3–5 min

Call Month Time Summary

  • Chart review, care gap identification

    Timestamp: 7–11 min

  • Greeting, meds, care plan, appointments, SDOH, wrap-up.

    Timestamp: 18–28 min

  • Call notes, care plan update, follow-up actions

    Timestamp: 11–17 min

  • Full call month — all phases documented,

    Timestamp: 36–56 min

  • Patient Contact: Portal message or none

    Primary Activities: Chart review, care gap check, portal message, coordination

    Timestamp: 10–15 min

  • Patient Contact: Phone call (20–30 min)

    Primary Activities: Full review, care plan update, med rec, goals

    Timestamp: 30–40 min

Monthly Tracking at a Glance

  • Always call from a quiet, private space to protect patient confidentiality (HIPAA).

  • Never rush the patient — a thorough call month prevents gaps in the off month

  • If the patient doesn't answer, leave a brief voicemail, document the attempt with a timestamp, and try again within 48 hours.

  • If a patient asks to reschedule, honor the request and document the new target date in the care plan.

  • Use open-ended questions: 'How have you been managing your medications?' not just 'Are you taking them?'

  • Document during the call when possible — don't rely on memory for post-call notes.

  • If a patient discloses a new or urgent symptom, escalate to the provider same day and document immediately.

  • Always confirm the patient's preferred contact method and time before ending the call

Call Month Best Practices

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Contact Resource & Tools Directors Amanda Lewis or Chrissy Knotts at Support@Mxviii.com if the SOP or Guide you need is missing.

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