Improving healthcare infrastructure is pivotal to ensuring absolute care for the needy. One of the most innovative approaches to executing it is Chronic Care Management (CCM). It offers a transformative approach to healthcare delivery.
Chronic Care Management (CCM) can remold the treatment of individuals battling chronic conditions.
But what is chronic care management in all practical sense? CCM can treat patients with chronic disease, thereby bettering clinical outcomes. And why is it endorsed while cutting down expenses?
Chronic care management goes beyond the definition of a medical line of treatment. It represents a profound shift towards proactive preventative care. CCM contributes to empowering patients to better their health conditions for the future.
A startling number of people – both young and adult- in the United States struggle with a chronic disease. Cancer, heart disease, and diabetes rank as the leading causes of death in the country today.
Common chronic diseases comprise most of the country’s mammoth annual healthcare costs.
CCM can benefit you by monitoring your chronic conditions. This blog will explain what conditions qualify for chronic care management, its requirements, and how to be eligible for it.
What Is Chronic Care Management?
Chronic care management is a rewarding Medicare program. It provides reimbursement for providers of beneficiaries against their services beyond duty hours. CCM recognizes two or more chronic conditions.
Patients can bounce back to life post-chronic care management. Furthermore, they can manage symptoms and prevent complications with CCM. They have fast become a vital cog across all healthcare and community settings in the States.
CCM services include tailored care strategies and day-long virtual access to medical professionals. They also help patients manage their lives through self-management.
You will also find electronic health record systems in CCM. They function to exchange patient information across providers without interruption. As a strategic line of treatment, they have yielded outstanding health outcomes and generated surplus revenue for caregivers when executed at scale.
CCM programs improve the patient experience by ensuring a coordinated approach to care. They also reduce hospital readmissions and emergency room visits.
Providers can also rely on a guaranteed revenue channel through Medicare reimbursements. CCM works to align patients and healthcare providers with their respective goals. It drives the development of the healthcare landscape.
Who Should Consider Chronic Care Management?
Chronic care management covers patient care outside the traditional clinical office setting. It functions by developing and managing a comprehensive care plan. It will incorporate care coordination services and applicable medications and maintain regular communications.
To qualify for CCM, you must have at least two chronic conditions, if not more. Chronic diseases are long-term ailments that require active management and coordination throughout life.
We have listed the different types of chronic diseases to help you understand.
- Cancer
- Chronic obstructive pulmonary disease (COPD)
- Heart disease/cardiovascular disease
- Hypertension
- Diabetes
- Stroke
- Alzheimer’s disease
- Chronic kidney disease
- Hyperlipidemia
Who Can Provide CCM Services?
Chronic care management is available in physician offices. Furthermore, Critical Access Hospitals and Federally Qualified Health Centers can do the same. Here is a list of healthcare professionals who can bill for Chronic Care Management:
- Physicians
- Physician Assistants
- Nurse Practitioners
- Certified Nurse Midwives
- Clinical Nurse Specialists
CCM pays one practitioner or facility per patient in a calendar month. The billing healthcare professional can provide Medicare-compliant “incident to” services. The practitioner must conduct a face-to-face visit and obtain verbal or written consent from the patient. Furthermore, they must develop a comprehensive care plan in the EHR to begin CCM services.
What Conditions Qualify For Chronic Care Management?
CCM is available to patients battling at least two chronic conditions. The conditions must last at least a year to qualify for Medicare and show a functional decline.
Below, we have explained what conditions qualify for chronic care management. Despite them, the providers should be responsible for determining the CCM eligibility of patients.
1. Congestive Heart Failure (CHF)
Congestive heart failure (also called heart failure) is a serious medical condition. People facing it struggle with irregular blood pumping in their hearts. Heart failure does not imply literal failure in cardiac functioning despite its name.
Most elderly people in the United States struggle with Congestive Heart Failure (CHF). It ranks as the leading cause of hospital admission and readmission today. CHF tops the 30-day hospitalization rate among surgical and medical conditions.
CHF is progressive and worsens with time. Surprisingly, one in four heart failure patients needs readmission within 30 days of discharge! Proper treatment and medical backup are required to manage symptoms. Cutting down on readmissions could benefit organizations by reducing healthcare expenses.
2. Chronic Obstructive Pulmonary Disease (COPD)
Although CHF occurs in the heart, COPD affects the lungs. Chronic Obstructive Pulmonary Disease is a progressive lung disease that compromises your breathing. It leads to inflammation and blocked airflow inside the lungs.
A mammoth 15 million US adults have reported their struggles with COPD. Many are unaware of the condition within them. A gross 147,382 people have lost their lives to chronic obtrusive pulmonary disease. COPD is the sixth-leading cause of death in the US, as per the Centers for Disease Control and Prevention.
The respective impact of both chronic bronchitis and emphysema varies. This is despite most people facing these conditions when battling COPD. Moreover, acute exacerbations of chronic obstructive pulmonary disease also drive hospitalizations. It contributes in notable numbers to COPD costs.
3. Diabetes
Diabetes is affecting a rough 29 million people in the States today. Another 8.5 million people are struggling with it without taking any diagnosis. If combined, this sums up 11% of the U.S. population. Diabetes needs constant supervision to avert any possibility of ominous medical complications.
Adequate management is necessary for diabetes to improve patient health. You can explore as many as 1,400 apps from the market to treat diabetes patients. But not all of them share equal attributes. Remote patient monitoring services can provide a detailed snapshot of the patient’s health.
Patients will adopt chronic care management solutions that provide access to their health data and allow them to exchange data with their healthcare providers. We recommend self-management of diabetes to support lifestyle modifications. Learn about the benefits of telehealth before exploring the related platforms.
4. Hypertension
Hypertension is prevalent among roughly half the total adult population in the country. It is necessary to mention that the risk of high blood pressure rises with aging people.
Ignoring the symptoms of hypertension can lead to severe health issues. They could range from stroke, kidney damage, heart failure, and heart attack. Hospital readmission is also a common affair among older hypertension patients.
Several hindrances can compromise the proper treatment of hypertension. They could include poor blood pressure management techniques or poor patient participation in their care. RPM (Remote Patient Monitoring) allows physicians to address these issues by developing an effective measurement technique.
How Chronic Care Management Works?
There’s no denying that patients often take a reactive approach to health care. They seek medical intervention only when they get sick or injured. A chronic care management program focuses on proactive, preventative care.
An effective CCM program brings several crucial components under one plan. CCM aims to deliver optimal care. These components include:
1. Care Team Coordination
The CCM treatment model begins with care team coordination. The program involves managing collaboration between the healthcare professionals involved in patient care. It brings everyone responsible to the same page about the patient’s needs.
Care team coordination guarantees efficient care by functioning as a team. A group of healthcare providers joins forces with a primary care physician. They concentrate on delivering tailored care to the patient. The team will also feature specialists, nurses, pharmacists, and care coordinators.
2. Care Plan Development
Developing a care plan is the next step in patient care for chronic diseases. It will assist medical professionals in modeling aspects of patient care according to a timeline, which can also benefit them.
The goal of care plan development is to support the patient’s physical and mental care. Every patient who signs up for a CCM program follows a tailored care plan, which includes medication management and preventive measures to yield optimal care.
3. Regular Health Assessments
Routine health checkups in CCM involve tracking the patient’s health status. The experts will check their chronic conditions through health assessments and lab tests. The purpose behind running these evaluations is to determine potential complications.
Moreover, it provides an opportunity to adjust treatment plans as needed. All these will take place while adhering to a coordinated care approach. We have listed the common assessments in CCM to track progress over time.
- Lab tests and diagnostic screenings
- Vital sign monitoring
- Physical examination
- Medication review
- Nutrition and Lifestyle Review
- Functional assessment
- Symptoms and progress monitoring
- Care plan update
- Mental health assessment
24/7 Patient Access
Any patient under CCM plans can contact the practice instantly if necessary. This allows them to address any urgent chronic care needs without delay, giving them access to care around the clock.
Chronic care management programs ensure uninterrupted access to their care team. They achieve it through telemedicine, among other remote communication channels. The accessibility of the offer drives instant responses to health concerns.
How Chronic Care Management Works With Remote Patient Monitoring (RPM)?
CCM employs RPM to gather health data of patients with chronic conditions at home. They assist the caregivers in making educated treatment adjustments. All this is possible without resorting to routine in-person visits.
CCM through RPM results in bettering chronic disease management. We have identified the effective ways to address chronic conditions:
- Virtual visits: Virtual meetings can help patients meet physicians regardless of location. The healthcare professional can check symptoms and review medication. They can also educate the patient about their care plan.
- Symptom surveys: Routine assessments help chronic care management providers gather real-time data. They can learn about the present health conditions of the patient. They can provide new medications if the symptoms of chronic diseases are shifting.
- Medication Reminders: Most patients with chronic conditions take medication to ease symptoms. Medication reminders encourage patients to take the correct dose at the right time. They do not include medical administration but an oral or visual reminder instead.
CCM, through RPM, helps patients transfer real-time data to clinicians. It also encourages patients to assume better control of their health. RPM functions as a vital tool for healthcare facilities. It ensures uninterrupted and economic management for chronic conditions.
Benefits of Chronic Care Management
The pursuit of improved care is leading medical physicians to embrace new programs. Most of them claim to deliver refined care for their patients.
Chronic care management care can be a challenging shift for people who need extra care. They may struggle to keep up with the programs and the assured changes.
We have identified the benefits of CCM services in helping their case in front of a skeptical audience.
- Access to Care
8 of 10 patients show a reactive approach to healthcare. They only step out to consult with medical experts only when they get sick. In a CCM program, the physicians focus on proactive care.
The physicians follow a routine of monthly telephonic and virtual check-ins. These allow the Medicare beneficiaries to express their concerns and urgent needs. Also, preventative services like CCM guarantees around-the-clock care.
The double-header approach reinforces the goal of chronic care management services. The extended availability of physicians makes CCM a powerful tool. The heightened access to care contributes to reducing patients’ functional decline. Moreover, it can also cut down on emergency room visits and hospitalizations.
- Health Care Savings
Patients in CCM get financial respite from limited annual healthcare expenses, even if they have a small monthly coinsurance cost. CCM services can benefit patients by cutting healthcare spending in many ways.
- CCM keeps patients with chronic diseases out of the hospital. Patients under preventive care no longer have to worry about unexpected medical expenses. They also help identify health issues early, when they are easier and cheaper to treat.
- An uninterrupted nurse line assists a patient during a non-urgent issue. A dedicated hotline allows patients to reach their physician at any time of day or night. It can help them save money by availing medical advice.
- Achieving Health Care Goals
Healthcare professionals work on supporting patients with the necessary tools for self-management. It aids them in their chronic conditions care. The clinicians approach these conditions for treatment in conjunction with specialty providers. It enables them to establish goals for speedy health recovery.
These goals will be featured in the patient’s detailed care plan for future reference. CCM services need detailed care plans that are always accessible. The healthcare experts record their interaction with the patient in this document. The healthcare plan is available in the provider’s electronic health record (EHR). It is available to the patient, provider, and approved caregivers.
The experts will treat patients while referring to the care plan to track goals. The document holds immense value because it contains every possible detail. They can contribute to helping providers and patients achieve their healthcare goals.
Challenges in Chronic Care Management
Like every other process, CCM has its fair share of challenges. But, a practice of notable scale attends to an exceptional CCM team. They will need comprehensive CCM services instead of an in-house program.
We have discussed the common challenges that patients in the CCM program face:
- Busy providers: The medical management system often goes under the radar. Most resources function beyond their limits. It compromises their ability to meet the CCM patient’s expectations. CCM program can be a big challenge if the healthcare staff is lacking.
- Poor coordination: It seems hard to plan care and exchange data between clinicians. This is because CCM patients constantly interact with several providers. One medical professional may not be aware of a new diagnosis or medication. It could become an incomplete picture and affect the quality of care.
- Poor monitoring: Follow-ups keep the provider up to date about the patient’s development. Patients could suffer outcomes if the meetings are inconsistent.
The Role of Technology in CCM
There are a handful of applications available for healthcare management in CCM. Technology’s influence contributes to better connectivity and boosting accuracy.
Telephonic software and live texting can assist CCM programs in delivering precision-defined results. They address communication gaps and produce instant and responsive care prospects.
The rewards of technology in CCM elevate the care for older individuals. They struggle to commute between the provider’s office and home. The promise of easy contact simplifies the whole process and better chronic disease treatment.
Other innovative options include reporting and analytics software. This software improves care coordination by assisting every provider in checking on patient progress. Still, other healthcare technologies aid in beating Social Determinants of Health (SDOH) challenges, such as lack of transportation or other non-medical factors.
It is necessary to mention that healthcare technology also supports continuity of treatment and care. Data exchange through the cloud and EHRs are two options that improve treatment accuracy. They provide all the correct information about the patient’s medical journey.
One Health Makes Chronic Care Management Easy
In this post, we have expanded on the challenges and benefits of CCM and elaborated on what conditions qualify for chronic care management. However, many medical facilities avoid CCM due to insufficient time, knowledge, or staffing.
At One Health Medical Group, we strive to deliver comprehensive care. More and more people with chronic diseases are opting for our compassionate services. They are tailored to the distinct needs of our senior patients.
Call us for more information about our Chronic Care Program. We have the best professionals in the industry that can help you navigate your health journey easily.
At One Health, we have the potential to become your reliable partner in this field. We use extensive professional experience to offer valuable guidance in RPM implementation.