Chronic Care Management

Many skilled nursing facilities (SNFs) and other healthcare organizations care for patients and residents with chronic conditions. The National Council on Aging has found that almost 95% of adults over 60 have one chronic condition, and 80% have two or more. The reality is that an annual checkup isn’t enough. The aging population needs more than a yearly visit. They need chronic care management (CCM), and First Docs can help.

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What Is Chronic Care Management?

Chronic care management is a value-based care program described in Medicare Part B. Medicare and many Managed Care providers reimburses organizations for providing care for two or more chronic conditions outside of regular office visits. Medicare Part B defines a series of conditions that qualify for CCM, such as:

  • Osteoporosis
  • Diabetes
  • Cardiovascular disease
  • Arthritis
  • Alzheimer’s and other forms of dementia

Much like other Medicare programs, there are rules. For example, only certain types of professionals can supervise a CCM program — a physician, clinical nurse specialist (CNS), nurse practitioner (NP), physician assistant, or certified nurse-midwife. These providers lead a series of services, such as:

  • Creating personalized care plans
  • Coordinating care with specialists when required
  • Educating patients on self-management of their conditions
  • Referring patients to community resources
  • Refilling prescriptions
  • Giving patients dedicated access  to their care provider

The Goal of Chronic Care Management

CCM has two core goals — improving care outcomes and improving financial wellness.

CCM allows physicians and other qualified professionals to effectively manage chronic conditions, which is a major win for care outcomes. These conditions often come with complex care requirements that annual visits can’t keep up with. CCM plans ensure patients have access to the number of visits and resources they need to manage their conditions. 

Plus, CCM programs improve preventive care. Many chronic conditions last a lifetime, and symptoms can only be managed, not eliminated. CCM helps patients manage their symptoms while slowing the progression of disease. 

 

How Chronic Care Management Can Benefit Your Patients and Organization

With Chronic Care Management, organizations can:

  • Improve patient care outcomes: CCM allows providers to consistently track patients’ chronic conditions and connect them with the resources and specialists needed for preventive care. The result? Potential complications are addressed before they worsen, and patients have more positive care outcomes across the board.
  • Reduce hospitalizations: A more preventive approach to chronic conditions means patients need to be hospitalized less. CCM programs teach patients how to manage symptoms at home and give providers greater oversight to respond to risks before they worsen.
  • Enhance patient engagement: CCM gets patients more involved in their care decisions with self-management education, community resources, and at-home tools. These practices empower patients to take a more active role in their care, increase communication with care providers, and adhere to care plans. 

Expand access to care: A key element of CCM is to care providers. With this widened access to care, CCM overcomes the common barriers to healthcare, like transportation or time of day. Patients can immediately connect with their providers any time, anywhere.

CCM can help to reduce spending related to health complications and readmission to the hospital — a massive contributor to big expenses. Fewer patients need to rely on costly hospital care when chronic conditions are managed. Improved communication among providers equals care teams that can improve their use of resources.

Partner with First Docs to bring CCM to Your Skilled Nursing Center

First Docs is an internal medicine practice with a physician-first approach. Our doctors are on-site up to five days a week to provide the proactive medical management, leadership and engagement needed to improve patient care outcomes. With our help, Chronic Care Management post-discharge can become a natural extension of the care they receive while on site at your skilled nursing facility.

First Docs physicians are dedicated to your center and actively bring the focused care your patients and residents require. Contact us today to learn more.