iPatientCare Blog - How to Simplify Chronic Care Management

How to Simplify Chronic Care Management?

Chronic Care Management is considered as a critical component of primary care by the Centers of Medicare and Medicaid services. There is an increase in the amount of chronic diseases across the globe. Chronic care management has assisted healthcare teams to demonstrate effective and relevant solutions to this growing challenge. Currently, in the healthcare system it is difficult to prevent the diseases completely. CCM assists all the providers in demonstrating effective and relevant solutions to this growing challenge.

It is very essential to find an evidence based and effective strategies to promote health and to prevent and manage chronic disease. A single approach is not viable to manage a particular disease. A variety of changes for the management of chronic disease have been made and it is concluded that the most effective interventions for improvement in CCM includes the combination of multi-pronged strategies.

If there is an organized and multifaceted support for primary care teams, it positively affects the care of high risk patients. Operating from a set of philosophies that focuses on quality of life, overall health and well-being is part of CCM. This process empowers people to increase control, and to improve their health, must also choose an alternative to lifestyle and behavior-based prevention efforts. Resources relevant to chronic care management also recommends to have effective health promotion that follows and leads the community in addressing its requirements and developing strategies to meet those requirements.

To look in more details, to provide chronic care management services, practices need to have a trained practice staff to check patients with multiple chronic conditions identified within past 12 months. Secondly, there should be check on the chronic conditions that place the patient at significant risk of death, or functional decline. Also prepare a comprehensive care plan that has to be monitored, established, implemented, and reviewed.

For more complex chronic care management services, there are various other elements that are required for billing:

  • Chronic conditions can make patients more vulnerable to functional decline, or risk of death.
  • Moderate or high complexity medical decision making.
  • There should be 60 minutes of clinical staff time by provider or other qualified health care professional.
  • Multiple chronic conditions expected to last for a long time.
  • A comprehensive care plan that is established or revised.

CCM services can be billed by the providers, certified nurse practitioners and physician assistants. Chronic care management can be billed by some specialists and most frequently by primary care providers. CCM services is not within the scope for psychologists, podiatrists, or dentists, but these providers may refer or consult with them to coordinate and manage care.

Also, implementing CCM is a vital step towards achieving success with MACRA. The practices that do not implement CCM could gain less incentives as there is a shift from fee-for-service moving rapidly towards value-based care. CCM services can help practices generate additional revenue if conducted properly. Proper management of chronic conditions can enhance patients’ lives by reducing emergency room visits, reduce complications, reduce room visits, hospitalizations, and readmissions. CCM can overall improve patient satisfaction and health of patients which can lead to better quality and performance scores.

The prevention and management of chronic disease creates an opportunity to integrate population health which would broaden the Chronic Care Management by directing additional efforts in reducing the burden of chronic disease. The CCM supports the intrinsic role that the social determinants of health play in influencing, community and population health. Adapting to this expanded CCM facilitates a fundamental shift in understanding about how and where the individual patient care fits in. This shows that there is clear association between healthcare and the community. The action-driven CCM will broaden the focus of practice to work towards health outcomes for individuals, communities, and populations.

It is seen that chronic diseases occur most often in older adults. But nowadays, even some children and young adults are showing increase in chronic diseases as a result they are living with chronic condition for a long time, making chronic care management very vital factor to tackle with. Many models have been made to manage chronic care, but most of them include the following elements that are common:

  • Using health information system
  • Building community partnerships
  • Using best practice guidelines
  • Promoting proactive care
  • Identifying needed services based on risk stratification
  • Promoting self-management

Many solutions are complex as system-level changes, the providers can recognize different aspects of their practices using available resources. The provider can approach chronic care management on three levels – in the community, in the practice and in broader advocacy. The goal of a practice should be building confidence in patients and their personal care-givers. They must help them deal with their illness effectively, and improve their health outcomes. To promote self-care successfully, practices need appropriate primary care team, implementation support for the patients and adequate training.

The practices that outsource their CCM services can substantially increase their net revenue. Outsourcing the chronic care management is shimmering opportunity for the physicians to increase their outcomes and help more patients build new revenue stream by providing the reimbursement for the extra time and effort that are being invested in caring for chronic patients outside the traditional office visits. For patients, CCM helps in improving self – management by simplifying chronic care regimens and organizes care and interactions through a single patient portal. The combined solutions will provide enhanced level of connectivity that engages patients by improving communication between patients, providers and the care team.

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