Chronic Care Management: Services Your Patients Need

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by Lucy Lamboley

I'm sure we're all aware of the American way of life — the one where many of us actively partake in regular bad habits like smoking, drinking, consuming unhealthy foods, and look past our largely inactive lifestyles where only about 23% of us actually get the recommended 150 minutes of aerobic and muscle-strengthening exercise per week. While the impact of these not-so-great choices may be out of sight and therefore out of mind for younger people, the reality is that the delayed effects are just a ticking time-bomb of chronic disease waiting to happen.

Low Down on Chronic Care Management Services 

Unfortunately, about 40% of all adults in the United States suffer from two or more chronic diseases, with the majority of those diseases linking back to choices concerning poor lifestyle habits in our younger years. Once chronic disease has taken hold, patients and healthcare providers must kick into high gear to figure out how to mitigate the effects and prevent disease progression.  

The solution? Prevention would be ideal, but because most older Americans are already dealing with the fallout of poor choices, chronic care management services are often the best way to support patient efforts to achieve improvements in health and wellness. 

Understanding Chronic Care Management Services 

A helpful chronic care management definition is the one provided by the Centers for Medicare & Medicaid Services (CMS) for its Medicare beneficiaries. CMS notes that chronic care management services are care and support provided to patients that have at least two or more chronic health conditions that are expected to last at least 12 months or until the death of the patient. While chronic care management services are most often provided within the primary care model, there is no specialty-specific restriction, meaning that specialty care providers and their patients can benefit in building chronic care management programs for their patients. 

While any patient with two or more chronic conditions would benefit from CCM, it is most frequently associated with Medicare patients. CMS chronic care management services is a care model designed specifically for Medicare beneficiaries — and one that the federal agency is supporting more than many other models and programs. Thanks to changes in coverage and reimbursement for CMS chronic care management services, CCM has become one of the most lucrative Medicare programs and one that's delivering great results for patients, practitioners, and payers alike.  

Key Components of Chronic Care Management Services  

As the Bipartisan Policy Center notes, 68% of Medicare beneficiaries have two or more chronic conditions. These account for a whopping 94% of Medicare fee-for-service spending. While these statistics are reason enough alone for why patients should receive chronic care management services, it's also prudent that patients understand that CCM is both effective for managing their health and cost-effective for their own wallets — not just Medicare's. CCM services are providing physicians with the tools and financial incentive to develop programs that provide wraparound care to their patients, helping lead patients toward better symptom control and enabling them to gain the upper hand on their chronic health conditions. 

To best ensure your chronic care management program achieves its health and financial goals, it should be built according to CMS guidelines and supported by CCM technology that will better allow you to identify those patients who would benefit from the services, provide appropriate services, and then bill for and get paid for CCM.  

Let's look at some of the key steps required for the delivery of chronic care management services. 

Structured recording of patient health information 

Accurate and easy-to-read patient health information enables both patients and care team members to keep better tabs on the progress of the patient, support accurate billing, and allow for smooth and easy communications and transitions between community care providers such as specialists, social services, and hospitals. Chronic care management documentation for patients should include a problem list; cognitive, functional, caregiver, and environmental assessments; expected outcomes and prognosis; a care plan with measurable treatment goals, symptom management, medication management, and planned interventions; and any requirements for periodic review and care plan revisions. 

Development of and maintaining comprehensive electronic care plans  

Care plans act as the roadmap for chronic care management, giving the patient something to follow and helping them stay engaged in their CCM program. Care plans should be easily accessible for patients, have written goals, and include instructions and recommendations for reaching those objectives.  

Management of patient care transitions and other care management services as they arise 

Ensuring patients transition to other services when needed makes it more likely that they will be successful in meeting care plan goals. This also helps ensure that outside providers are privy to necessary care information, allowing them to better support the patient. 

Coordinating and ensuring patient health information is shared promptly as needed to outside entities 

Navigating healthcare is often challenging for patients. Ensuring that chronic care management documentation is received by entities that need it will help remove access barriers and potentially speed up the progress to wellness.  

Patient consent 

We wanted to briefly highlight patient consent because it is sometimes overlooked or not documented correctly. To enroll a patient in a chronic care management program, patients must consent to their participation. Prior to giving their consent, patients must be provided key details about CCM services, including their availability, the potential for cost sharing responsibilities, and the ability to stop services. 

Providing Chronic Care Management Services 

Chronic care management services are performed outside of the normal face-to-face office visit, are increasingly delivered virtually, and can be conducted with a qualified care team overseen by a physician or other non-physician practitioner like a nurse practitioner, certified nurse midwife, clinical nurse specialist, or physician assistant. From a patient perspective, these extra support services and more frequent check-ins can really help keep them on track, motivated to succeed, and engaged in their care. Between the round-the-clock support, 24/7 access to care and health information, and the continuous relationship with their care team members, the patient becomes better engaged and connected to their chronic care management program and goals simply because they have the necessary tools and information to help them succeed.  

Getting Patients Started On Chronic Care Management Services 

Patients don't always know when something like chronic care management is available to them, and identifying those patients who qualify for chronic care management services can sometimes be challenging. Thankfully, a great place to start building awareness about the CMS chronic care management service program is during the Medicare annual wellness visit (AWV). The AWV is a great, cost-free service to patients — one that provides an opportunity for patients to discuss their general lifestyle while receiving an assessment of their past, present, and future health concerns. If the AWV determines that a patient has two or more qualifying chronic conditions, enrollment into chronic care management services would be a win for the provider organization and most importantly, a win for the patient.  

Once a patient is enrolled and participating in chronic care management, it's vital that their comprehensive care plan is both individualized and person-centered based on their physical, mental, cognitive, psychosocial, functional, and environmental assessments. There really is no one-size-fits-all chronic care management model here, even for patients with similar chronic disease profiles. This is the beauty of CCM services. They truly meet the patient exactly where they are and provide them with the tailored support they need — no matter their situation.  

While it's unfortunate that chronic diseases are such a significant challenge for so many Americans, we are fortunate that chronic care management is getting the federal support it needs to help more patients better manage their chronic diseases and get to a point where those diseases no longer control their everyday lives. Chronic care management is truly the services patients need to live longer, healthy, more productive lives.

Medicare Annual Wellness Visits Register

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