Comprehensive care management — also known as "virtual care management" — combines aspects of chronic care management (CCM), remote patient monitoring (RPM), and other billable preventive services to allow providers to take a whole patient approach to managing the medical, functional, and psychological needs for medium- and high-risk patients. For clinicians, comprehensive care management provides patients with the wraparound care they need, not only promoting wellness but also treating and helping prevent acute exacerbations of chronic health conditions. To be successful, it is important that any care management approach be a team effort, eliciting buy-in from the patient's entire healthcare team as well as the patient themselves.
The American Academy of Family Physicians defines comprehensive care as "the concurrent prevention and management of multiple physical and emotional health problems of a patient over a period of time in relationship to family, life events and environment." Like many facets of our healthcare system, comprehensive care management is a broad term attributed to what may be initially viewed as a cumbersome program to implement as there are not specific blueprints for providing the service and program details can look a little different from patient to patient. Helping patients understand exactly what the service means for them and how positive health outcomes can be achieved through it will go a long way in gaining their support and active participation in a comprehensive care management program (CCMP).
What Patients Should Know About Comprehensive Care Management
To achieve patient buy-in and engagement, it's important they fully understand their health conditions and the reason(s) why they need and would benefit from care management services to begin with. Once they understand the why, patients can better understand that comprehensive care management will create a support system to help them properly manage those health conditions. In doing so, they should gain better health stability, overall improved wellbeing, and maybe even attain a higher quality of life.
The need for care management services is often identified and ordered during an annual wellness visit (AWV). The Medicare AWV offers the practitioner the perfect opportunity to review the patient's health history and their chronic health conditions. To have a successful conversation about comprehensive care management, there are a few things your patient should understand.
How to Qualify and Provide Consent
Under CMS chronic care management guidelines, Medicare beneficiaries with two or more qualifying chronic health conditions that are expected to last at least 12 months and place the patient at significant risk may qualify to participate in chronic care management (CCM) services. The list of qualifying chronic conditions includes everything from physical ailments such as arthritis, asthma, diabetes, cancer, Alzheimer's disease, and dementia to mental health issues such as depression. Patients with fewer than two chronic conditions, or who otherwise are ineligible for CCM, may also benefit from care management programs like principal care management (PCM) or remote patient monitoring (RPM). Learn about these and other preventive care key concepts in our glossary.
Patients will need to actively choose to participate in care management services, indicating that choice either verbally or in writing. For patients, discussing consent will not only help them understand that they need to play an active role in their care, but it will also make them aware of any out-of-pocket costs they may incur.
When obtaining consent, documentation in the patient's medical record must state that care management services are available and offered, provide information about cost sharing, identify the furnishing provider, and include notice that the patient can choose to stop care management services at any time.
Who, What, and How of Comprehensive Care Management
Comprehensive care management can help patients achieve better health by providing more encompassing support for their healthcare needs. For patients, this support can mean quicker responses to questions or concerns, better coordinated care with outside healthcare providers (e.g., specialists), quicker responses to medication management concerns, and direct, around-the-clock access to their healthcare team.
During a patient's initial comprehensive care management visit, a patient and their practitioner should work together to establish a list of the patient's health problems as well as expected outcomes and prognosis. To address the problem list, the patient and provider will discuss symptom management and identify treatment goals and planned interventions while identifying who is responsible for each intervention. A medical device may be given to the patient for tracking vital measurements pertinent to their condition list. To promote the wraparound care, community and social services should be ordered, if needed.
It's important for patients to understand how convenient comprehensive care management can be for them. The service means their healthcare team is now available to them 24 hours a day, seven days a week, all without requiring additional trips to an office. The patient can receive care and advice through several different means including telephone and secure web portal. While the occasional in-person check-in with their practitioner is required, the bulk of care is done behind the scenes by the care team through patient check-in contacts and coordination of care among all the patients' healthcare providers.
Communication is Key to Helping Patients Achieve Better Health
In the United States, a big barrier to achieving good health outcomes is a health literacy disconnect between patients and clinicians. This often leaves patients unsure about their care and how to navigate the complex medical system. As providers of healthcare, it's important for clinicians to recognize this health literacy gap and position themselves as good communicators, better ensuring they communicate and collaborate with patients at a level they are comfortable with.
To elicit the strongest buy-in from and achieve the best outcomes for patients, particularly concerning the provision of comprehensive care management services, it's important that communication is clear and accomplished in a way that allows patients to fully understand what is being asked of them and why. Ultimately, when good communication is achieved, practitioners end up with higher patient satisfaction rates, better health outcomes, and, most importantly, healthier and happier patients.
