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The What and Why of Chronic Care Management

About a third of the American population has multiple chronic conditions. These chronic conditions - long-term health problems such as diabetes mellitus, cardiovascular disease, allergies, asthma and anxiety disorders - are costly to manage and contribute to the bulk of healthcare spending.

Patients with chronic conditions account for the majority of all primary care visits, and over 90% of all Medicare spending goes toward treating people with chronic conditions. Patients with multiple chronic conditions are also a major source of hospitalizations - 70% of all inpatient stays are for people with 2 or more chronic conditions.

Healthcare systems could be doing a better job managing chronic care patients. Improving the health of these patients could lead to the prevention of secondary complications of disease and a reduction in emergency room visits, hospitalizations, and readmissions. Primary Care Practices have become de facto care coordinators for patients with multiple chronic conditions. Because of this, Medicare and other HMO’s started the Chronic Care Management (CCM) program as a new option that helps engage and manage such patients between office visits.

Options Available to Physicians – The Chronic Care Management (CCM) Program:

A recent study showed that nearly half of Medicare patients readmitted to the hospital within 30 days had no post-discharge contact with healthcare professionals. Patients with multiple Chronic Conditions have better outcomes when they are given tools to promote better self-care and have a skilled resource to help coordinate care amongst multiple providers.

Patients also receive better continuity of care when a practice develops a holistic view of the patient’s needs - including their functional, social, physical, and mental health needs - and provides a point of regular contact for the patient. The Chronic Care Management (CCM) program addresses this gap in care by providing management of patients between office visits.

Chronic Care Management assists in care coordination by:

  • Offering communication, engagement and monitoring of patients by a team of clinical staff consisting of RNs, LPNs and CMAs

  • Assisting and encouraging patients to follow physician-approved care plans based on physician-provided diagnostic codes and additional patient input

  • Engaging in monthly non-face-to-face patient contact

  • Ensuring that the physician is current with care plan updates, enabling better patient-centric care

  • Where the need arises, discussing, directing and assisting patients with socioeconomic requirements

  • Enabling periodic medication reconciliation and assistance to patients with refill requirements; reviewing adherence and potential interactions; documenting and updating any OTC medications consumed

  • Providing 24x7 access to clinical staff and providing patients and caregivers the means to make contact with clinical staff in the case of emergency

  • Ensuring continuity of care through clinical staff to schedule appointments for follow-up visits

  • Facilitating the oversight of patient self-management of medications

Simple actions = Big positive effects

Greater vigilance for patients with chronic conditions does not have to be difficult and can be a key to healthier outcomes and lower healthcare costs. In addition, programs which provide “care beyond the walls” in the home or outpatient settings not only help delay or prevent complications and costly interventions, but also can improve a practice’s performance under the Medicare Access and CHIP Authorization Act (MACRA).

Chronic Conditions

There are more than 50+ Chronic Conditions that are eligible for CCM Services. Broad categories of the most common chronic conditions are as follows:

  • Addiction/substance abuse – Alcoholism, Opiate abuse

  • Autoimmune diseases – Osteoarthritis, Rheumatoid arthritis

  • Blood disorders – Anemia, Leukemia

  • Cancer - Breast cancer, Colorectal cancer, Prostate cancer

  • Cardiometabolic conditions - Congestive heart failure, Diabetes, Dyslipidemia

  • Chronic pain - Resulting from various diseases in various therapeutic areas, e.g., autoimmune diseases, cancer

  • Endocrine disorders - Addison’s disease, Hypothyroidism

  • Eye conditions – Cataracts, Glaucoma

  • Gastrointestinal diseases - Crohn’s disease, Gastroesophageal reflux disease

  • Infectious diseases - Hepatitis C, HIV

  • Kidney diseases - Chronic kidney disease, End-stage renal disease

  • Lung diseases – Asthma, Chronic obstructive pulmonary disease, Emphysema

  • Mental disorders - Bipolar disorder, Depression

  • Neurological diseases - Alzheimer’s disease, Multiple sclerosis

  • Urologic diseases - Benign prostatic hyperplasia, Interstitial Cystitis

Enable Healthcare In., (EHI) is a leader in CCM Technology Platform and CCM Services performed by a team of 60+ trained nurses.

By: Anthony Subbiah

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Tel: 973 200 7300

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