Chronic Care Management

Nov 15, 2019 · 4 min

Patients go to the doctor when they’re feeling ill or when they need a check up, but what happens to them in between the visits? Will the patient follow their doctor’s recommendations, stay on top of their medication, or even go to the check up appointment? Effective self-management isn’t the most common skill people have, so periods of time between appointments can be worrisome, especially for patients with chronic conditions who have more complex needs and require additional care. It’s unrealistic, costly, and strenuous for these patients (and their healthcare providers) to book weekly, even monthly appointments, so what’s the solution? 

What is Chronic Care Management?
Chronic Care Management (CCM) became the solution on how to care for patients outside of the clinical appointment settings in January 2015 when the Center for Medicare & Medicaid Services (CMS) implemented billing codes that provide reimbursements for an array of activities done between appointments in the practice. These billings codes take care of Medicare patients with multiple chronic conditions who require a minimum of 20 minutes a month of in-person or non face-to-face contact between regular clinic visits, which refers to any communications or collaboration of care pertaining to the patient’s chronic pain and medication management. CCM has become a critical component of primary care as it focuses on value based care to support higher quality healthcare. 

What Happens in CCM?
It’s just as simple as the name suggests; CCM is a service provider’s use to create a comprehensive and coordinated care plan to better care for patients with chronic conditions such as diabetes, high blood pressure, and asthma. The goal of CCM is to provide ongoing care and management to better manage a patient’s conditions, enforce medication compliance, alleviate pain, and to achieve an overall better quality of life. 

Why is CCM Important?
The truth is, it’s easy for patients to fall behind on independently managing the important components of their care, such as keeping up with their medications, remembering to check their blood pressure, or even struggling to find transportation to an appointment. This is where CCM comes in, as it provides collaborative care to patients outside of their regular appointments to help them be happier and healthier. 

Along with caring for patients outside of the clinical setting, CCM offers an array of benefits to both patients and the practice, including:

· Increased patient engagement and satisfaction
· Improved medication compliance
· Fewer hospitalizations and ER visits
· Patient has 24/7 access to care team in case of emergency
· Patient receives increased knowledge and holistic understanding of their health
· Augments revenue for the practice
· Additional services to offer patients
· Reduced overall healthcare costs and transportation
· Real-time monitoring of patient data
· Improved communication and coordination among multidisciplinary care team

Communication Strategy
It’s clear to see how CCM is an integral part of the practice that doctors should treat as a separate program for eligible patients, but how should provider’s explain the program to their patients? It’s critical for providers to explain the program effectively so that patients can understand the full value of the service and the benefits that it offers. 

The steps to integrating CCM into your practice are as follows:
· Educate patients and encourage them to enroll in CCM
· Explain the program’s value and how it works
· Provide information on how the patient may refuse, terminate, or transfer care at any time
· Receive permission for electronic communication of medical information with other healthcare providers, following state and local regulations
· Provide contact information of care team
· Explain the monthly assessment visits with the nurse via phone communication
· Provide all information on billing, insurance, and deductibles for the patient
· Give patient a CCM invitation letter with consent form and review participation agreement with the patient to confirm their understanding of the program

It’s important to also highlight to the patients that the program is not time-consuming as check-ins will only be 20 minutes every month, and also that the patient will have around-the-clock access to their care team and medical records. 

Remote Patient Monitoring
Remote patient monitoring (RPM) programs can be used to track a patient’s physiological data (blood pressure, pulse, glucose) remotely at home while electronically transmitting the data to the care team. RPM is an essential tool that can enhance CCM services as it allows for healthcare providers to monitor the patient’s health from home, intervene in the case of a medical emergency, and provides the care team better insight into the day-to-day health of the patient. 

CCM and RPM Use Case Scenario
A 70 year old patient with obesity, hypertension, migraines, and type 2 diabetes with which she was diagnosed nine years ago when presented with mild polyuria and polydipsia, has always been on the larger side with fluctuating weight problems. This patient enrolls in the CCM program along with RPM (wireless blood pressure monitoring) due to her uncontrolled hypertension. Her care coordinator calls multiple times a month to check in, helping the patient follow the doctor’s instructions and ensuring that the patient takes her medication every morning. 

After reviewing the patient’s blood pressure data for two weeks (measures taken twice a day, before and after medication), the care coordinator notices that the readings are disproportionate between morning and night. The care coordinator and physician use the data collected from the RPM devices to determine how best to revise the care plan to better manage the patient’s conditions. They decide to divide the same dosage (20mg) so that the patient would take 10mg in the morning and 10mg at night. After a month on the new regime, the patient reaches her ideal blood pressure goal and decreases her chances of long term complications and possible future decompensation. 

In this scenario, it’s clear to see the benefits that CCM offers to patients. The care coordinator was able to monitor the patient’s conditions, encourage them to follow the physician’s instructions, and revise the care plan as necessary to produce more positive results. Without being enrolled in the CCM program, this patient likely would have continued to suffer from her chronic conditions with her health declining steadily, making CCM a lifesaving resource for this patient and many more. 

CCM is an indispensable asset to use for patients with chronic conditions, as they have more complex needs and require additional care and attention. Investing in CCM programs is essential to providing value based care to patients while improving their health and overall quality of life, cutting long-term healthcare costs, and expanding service outreach to care for more patients.

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