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Chronic Care Management

Whether or not medical practices have heard about it, the federal government is moving ahead with changing the way it provides reimbursement for care of patients with chronic conditions. In 2015, The Centers for Medicare & Medicaid Services, or CMS, recognized Chronic Care Management – CCM – as a critical component of primary care. The Centers believe that an integrated approach to chronic care will contribute to better health – especially among the elder population. 

Chronic Care Management, or CCM, is the coordination of care services which are furnished outside of regular office visits. The target population is patients with two or more chronic conditions which are expected to last twelve months or longer, or until the patient’s death. These conditions often place the patient at significant risk of death or functional decline, increase the likelihood of multiple hospitalizations, and involve a high level of medical care and follow-up. 

As stated by Medical Economics, “Complex chronic conditions—such as diabetes, obesity, and other cardiometabolic disorders—are at the root of this problem, and often involve difficult treatment regimens that include medication and lifestyle changes. Treatment of these conditions typically falls to busy primary care physicians, who don’t have enough time to provide these patients with the counseling and life-coaching that treatment of these conditions often require. At the same time, physicians are financially judged on the health outcomes of these patients, leaving physicians in a bind.”

Even though chronic conditions require a high level of in-office care, there are steps you can take to enhance preventative care and develop at-home care plans for patients. By keeping appointments, having blood tests regularly and following medication guidelines, the number of in-office visits decreases without negatively impacting a patient’s health. Recognizing the importance of the patient-provider relationship for those with chronic conditions allows for better patient understanding of their care plan as well as an increased involvement in their own health. 

Medical Economics recommends the enactment of “motivational interviewing,” which encourages physicians to know their chronic patients on a more detailed level so they can provide more accurate care based on the individual’s motivations, triggers and daily life.

To learn more about developing an effective Chronic Care Management plan for your practice, read our Knowledge Drop here.

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