iPatientCare Blog - Is Chronic Care Management leading to improved health outcomes

Is Chronic Care Management leading to improved health outcomes?

The providers are doing their best as the CCM provides essential elements of good care for the people with chronic conditions, but there is a gap between what is known and what is actually done. The chronic care management (CCM) has lately launched new technology and services that support individual with behavioral health conditions, developmental disabilities and drug addiction. This new platform helps in identifying any care related gaps. The comprehensive care planning, care coordination and monitoring is the overall aim of the care team.

CCM is a critical component of the primary care. It contributes to better health and care for the individuals. The organized records of the patient health information, maintaining a comprehensive electronic care plan, managing transitions of care and other care management services, coordination and sharing patient health information within and outside the practice; is included in CCM service.

The Chronic Care Management (CCM) focus on characteristics of advanced primary care such as:

  • There is a continuous relationship with a designated member of the care team
  • Patient support for chronic diseases to achieve health goals
  • Patient access to health information
  • Preventive care
  • Engagement between patient and caregiver
  • Timely sharing and use of health information

Many organizations have shown impressive improvements in the health of those they serve. The chronic care management model has recognized a few areas that outline a system that uplift the high-quality chronic disease management. The areas are:

  • Must assess your organization’s current level of care
  • What changes are required to improve the Chronic Care
  • Share the care plan
  • Self-management support

The providers need to know the role caregivers play in different cultures. Better end-results are accomplished through use of evidence-based techniques. The provider team can use standardized assessments of patient self-management needs and activities to enhance its ability to support patients. These include knowledge, skills, supports and barriers.

Other Benefits of Chronic Care Management:

  • The Chronic care management also supports other quality programs such as Accountable Care Organizations (ACO), Medicare shared savings program, MIPS, and bundled payments for care improvement.
  • Robust risk stratification capability, enabling chronic care management workflow from high to low risk.
  • It also captures non-visit revenue with the third party.
  • Supports new behavioral health integration program codes.
  • Has intelligence tools that provide real-time data on CCM revenue and other key performance indicators.
  • Does advanced scheduling.
  • Has call center support technology to address the continuity of care and community outreach to the patients in between clinical visits.
  • The comprehensive medication management includes home delivery and adherence tools.

iPatientCare supports all the above benefits. Being patient-centered care plan, the solutions bring together all healthcare providers. iPatientCare’s Chronic Care Management also empowers the organizations who are participating in alternative payment models with a formal platform to foster care coordination, quality measure, medication reconciliation and care transitions.

Many people need health related guidance round-the-clock. Telehealth is also one of the ways that can make this process easier by giving patients and caregivers online platforms and digital health devices to share data and care plans. iPatientCare can guide your practice to use right methods and technologies that engages the patient and gives the provider the information he or she needs to improve management and outcomes.

The CMS estimated that about 70% of Medicare beneficiaries have two or more chronic conditions. This makes their providers eligible for Chronic Care Management services. Having this eligibility, it is seen that better care is provided to their patients.

The Medicare Chronic Care Management is viable for all. Patients with two or more chronic conditions get much needed care and guidance. Moreover, the providers get reimbursement for the same instead of paying to treat challenging conditions and escalating expenses later. The opportunities for better health, better reimbursements and increased savings is going to grow in near future.

The challenge lies in getting the providers on board and working with patients to provide education, periodic follow-up that helps people with chronic conditions. The providers should make sure that their patients stay on track and meet their healthcare goals. They can utilize some standardized assessments (confidence, support, self-assessment knowledge) of patient self-management needs and activities to enhance its ability to support their patients.


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