Chronic Care Management

What is Chronic Care Management?



Doctors or other healthcare professionals provide a Medicare Part B benefit known as chronic care management (CCM).

It is considered chronic when an illness or condition persists for a year or more, needs continuing medical care, or restricts everyday activities. Both physical and emotional ailments, such as diabetes and depression, are included.

In this article, we shall understand chronic care management in detail and how it developed over time to help people receive better facilities faster.

What Is The Management Of Chronic Care?

Chronic Care Management provides services additive to in-person patient appointments. A thorough and detailed electronic health record is among the most crucial components.

So what is chronic disease management and what it includes?

The patient’s diseases, prescriptions, allergies, medical history, demographic information, and previous healthcare providers are all included in chronic care management solutions. A thorough electronic record is crucial since many patients with chronic diseases see several healthcare professionals.

Patients with multiple chronic conditions are eligible for chronic care management solutions:

  • Alzheimer’s disease
  • Dementia.
  • Arthritis.
  • High blood pressure.
  • Hypertension.
  • Cancer.
  • Asthma.
  • Autism.
  • Heart disease.
  • Depression.
  • Diabetes.
  • Multiple sclerosis.
  • Lupus.
  • Virus-infected diseases like HIV/AIDS.

Patients may view their treatment plan and health information at any time, seven days a week, and can get in touch with their care team anytime. The goal of chronic care management (CCM), a billable Medicare service, aims to improve patients’ and doctors’ lives.

The patient’s care team may bill for time spent modifying the patient’s circumstances in accordance with CCM. This includes putting together a comprehensive care plan, utilizing remote administration and communication (typically over the phone), monitoring medicines, and coordinating treatment among clinicians.

Objectives Of Chronic Care Management

Here we shall point out the four major objectives that CCM aims to achieve—

Chronic Care Management objective

1. Quality-Assured Care

The care environment for patients who have several chronic diseases is frequently difficult. They could see several doctors and experts through several health networks. Patients may manage the various moving components of their care using a chronic care management program.

A coordinated care team works together to ensure that every aspect of the patient’s care is well-synced as one moving component in the software for chronic care management.

2. Prevention Of Treatment Irregularities

There are occasional gaps in the management of individuals with various chronic illnesses. Numerous factors, including inadequate communication, disarray, or a provider failure, may be to blame for this.

By ensuring the patient checks in at least once a month, Chronic Treatment Management helps prevent gaps in care.

3. Better Health

Patients are more likely to obtain improved health outcomes if someone is responsible for holding them accountable for their treatment plan.

Treatment coordination enables people to keep track of their prescriptions and notify medical professionals of any changes or warning signs in their care. As a result, chronic Care Management patients obtain better outcomes because all these moving pieces function together.

4. Revenue Generation

Chronic Care Management (CCM) is an addition to your practice to ensure that your patients are receiving the best treatment possible. As a result, a practice’s annual revenue per billing provider inside its company might increase by up to $85,000.

Working with a reputable CCM partner will assist you in streamlining your Chronic Care Management program and increasing income.

Main Problems Of Chronic Care Management

Main Problems Of Chronic Care Management

There are several difficulties that CCM clinicians must deal with, from the patients’ lack of involvement to the possibility of fatality. Some of these limitations are as follows:

  • Critically ill patients frequently become disinterested in their treatment, which prevents them from achieving the intended outcomes.
  • The likelihood of hospitalization and drug interactions increases as the patient’s chronic diseases worsen.
  • Patients with many chronic conditions are more likely to become disabled and require longer-term, more intensive care to maintain a high quality of life.
  • The complexity of chronic disease treatments makes it more difficult for patients to handle them.
  • Chronic care management comes with a hefty price tag.

Evolution Of Chronic Care Management

Since CMS created new payment codes to cover the expense of managing chronic care remotely, the chronic care management software program has been in operation.

Even though this was a positive development, only a small portion of Medicare patients get treatment using these codes. Therefore, it will be challenging for the providers to deliver better results if patients are not engaged in the treatment process.

In order to afford the expenditures of their personnel and technology, many physicians struggle to sign up enough patients for this service. In addition, many chronic care management businesses have shut down due to their inability to make the model work.

The aim is to have a pool of skilled nurses who can collaborate closely with medical staff members. It’s also crucial to have simple technology to integrate with the EHR so that doctors can avoid wasting valuable time setting the system up.

The following areas of concentration are crucial for creating new models of care delivery, according to preliminary findings from the Health Evolution Forum, a group of almost 200 CEOs from providers, payers, and life sciences. First, reinventing primary care; advancing cutting-edge home-based chronic care models. Finally, leveraging value-based payments improves health care’s value and resilience.

What Should Be Done In The Chronic Care Management Model?

Chronic Care Management Model

Understanding the chronic care management model is crucial if you decide to build the software. This model will act as your blueprint, the base where you must develop your plan of action.

The Chronic Care Model can benefit numerous chronic diseases, healthcare settings, and target demographics. The end result is cost savings, happier doctors, and healthier patients.

The components of a Chronic Care Management model include the following:

  • Community.
  • Health systems.
  • Self-management assistance.
  • Delivery system design.
  • Decision support.
  • Clinical information systems.

When creating software for chronic care management, the aim should be to optimize each one of these six components.

If you want to implement system change successfully, you must redesign care across all six Clinical and Delivery Model components (CCM). Next, you will create a new system that integrates with your acute care procedures. The subsequent phases in this guide help you narrow down where you may begin implementing these improvements.


Tags benefits of chronic care management chronic care management certification chronic care management guidelines 2022
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