iPatientCare Blog - How to control diseases through CCM program

How to control diseases through Chronic Care Management program?

The chronic diseases can be influenced by health-related behaviors; which can be non-communicable and long-lasting illnesses. The term itself means, disease management for chronic conditions. Some of the diseases for which chronic care management successfully conducts and manages educational activities include diabetes, hypertension, osteoarthritis, mental illness, lupus, multiple sclerosis and sleep apnea.

Chronic diseases are often seen in adults from age of 35 and 65. But nowadays, children and young adults are also showing increasing rates of chronic diseases. These chronic diseases can have a significant impact on child development. Children and adults experience different types of diseases. Generally, these diseases cannot be prevented by vaccines or cannot be cured completely as their conditions are prolonged. Chronic conditions are:

  • Increasing world-wide
  • Are seriously challenging current health care systems and testing its ability to meet the long term health needs

The chronic diseases are having significant impact on child development. Some of the examples of the diseases faced by the children are – asthma, diabetes, and cancer.

Here, the work involves motivating patients to persist in necessary therapies and interventions by helping them achieve an ongoing and good quality of life. Providing patient-centered primary care can contribute to improved clinical health outcomes for patients with chronic diseases. The primary care providers must provide actionable advice about how to improve quality of life, minimizing stress, preventing secondary conditions and preventing the onset of diseases for those at risk.

Some background of Chronic diseases:

Chronic diseases are complex and share common risk factors. These factors are combination of genetic composition and age that cannot be modified. The unhealthy diets, alcohol abuse, use of tobacco, and physical inactivity (excessive body weight) are some of the common behavioral risk factors. These risks can lead to chronic diseases such as coronary heart disease, hypertension, osteoarthritis, and some types of cancers.

Some illnesses are not specifically medical-related, but involve patients and their interactions with families and workplaces. Interventions require patients and families to make difficult lifestyle changes and educating them on the benefits of the treatment. Patients need to be motivated for the treatment procedures so that they can observe an improved state, rather than the expected result – cure.

Chronic care management assist patients to systematically monitor their progress and coordinate with experts. It also identifies and solves the problems they encounter during their treatment.

Social determinants also contribute to the behavioral risk factors. Some of them include – Poverty, and poor nutrition due to low levels of physical activity and alcohol abuse. In this manner, chronic diseases and social determinants of health are related.

What is the role of primary care provider?

The practices should implement practical chronic care management strategies. This in turn, demonstrates the well-organized family practices that have a significant role to play in mitigating many of the risk factors and costs associated with the chronic diseases.

Active management strategies can help prevent or delay immediate or long-term depression. For instance, a patient with long-term depression can benefit their health-related quality of life. In long run, it contributes to better outcomes and help the patients to positively navigate the health care system. Also by working with other health care professionals, there can be a relationship of trust that will allow continuity of care and comprehensiveness.

This patient-centric approach, led by primary care providers is the most appropriate way for providing chronic care management. If properly organized and supported, this approach can prevent or significantly mitigate the effects of the chronic diseases. Some of the elements used to tackle chronic care management:

  • Using health information systems
  • Using best guidelines
  • Promoting self-management
  • Promoting proactive care
  • Giving acknowledgement to the primary care as it is hub for management support
  • Building community partnerships
  • Streamline approach for related conditions (common program for metabolic-syndrome conditions – diabetes and hypertension)
  • Family-centered approach (family members play a significant role in managing chronic conditions)
  • Applying self-management tools helps patients with comorbidities to manage their overall care

From above, it appears that chronically ill patients are better cared for under primary care providers. A purely biological care is inadequate, considering the diverse nature of chronic health problems. Here psychological environments come in picture and biopsychosocial model of care is an ideal alternative.

In other words, the disease prevention and management is an approach to health care that emphasizes helping individuals maintain independence and stay as healthy as possible through prevention, early detection, and management of chronic conditions.

This is known as continuum care, that ranges from prevention strategies directed at minimizing or eliminating future chronic illnesses by taking initiatives to encourage healthy eating habits and physical activity programs. This way patients are encouraged to actively take part in their own care and there is also support from health care providers with necessary resources and expertise to better assist their patients in managing their illness.

Developing Community Partnerships

Many practices have started referring patients to effective and accessible community programs. The practices that link clinical services and community supports, are giving assurance to their patients with high risk of chronic diseases; that they have access to the required resources to prevent or manage their conditions.

Developing community partnership includes –

  • Collaborating with other local health care professionals
  • Establishing partnerships with other health services to improve community and population health
  • Knowing about services offered in the community and linking patients to them as needed

Why use Chronic Care Management?

The reimbursement for the Chronic Care Management services are the cause of frustration for many providers as it is a cumbersome and a complex process. Chronic Care Management has lot of weightage in value-based reimbursement and therefore the providers should give primary focus on quality of care. The chronic care management program allows the providers to proactively manage, chronically ill patients outside the normal office setting and be reimbursed for those services. iPatientCare is ideal for the providers who want to transform their practices, thrive in value-based care reimbursement and improve quality of care. Some benefits of participating in CCM program are:

  • Cost control
  • Fewer admissions and readmissions
  • Progress towards meeting MIPS requirements

Ultimately, the Chronic Care Management programs should always improve patient care and get higher patient satisfaction. For instance, patients who follow the proper instructions after their discharge from hospital are less likely to get readmitted. Participating in chronic care management program also fulfills CPI activities, addresses resource or cost by decreasing unwanted interventions and encourages use of EHRs.

Chronic diseases cannot be addressed with medical care alone. Most important thing is to prevent it from becoming more prevalent. The root cause of such diseases are usually social determinants. These social conditions lead to poor health and contribute to developing chronic diseases. Keeping this in mind, the practices have powerful voice of advocacy for social and health policies that have significantly positive impact on the patients’ health.

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