Chronic Care Management
by Dr. Kent Niss
Chronic care management (CCM) is a program that is closely tied to my job as a family physician and this week I would like to shed some light on this unique program and what we, at PCMH are doing to engage patients in this opportunity.
In primary care we take care of the person as a whole, not just their cardiac or orthopedic or other specialty areas. This means really getting to know each and every one of my patients; what medical conditions they have, the medications they take, but also how many steps to get into their house or do they have a dog, do they go to the Senior Center for lunch or do they make their own, are they able to put their shoes on easily and can they get the things they need for each day. These are a lot of really subtle details that unfortunately I do not always get the time to discuss with my patients. This is where CCM comes into play.
CCM is a program that a patient can enroll in that will connect them with a person or team that allows them a 24/7 touch point to their health care team. Most commonly this is a nurse but can also be a case worker or social worker as well. This is a Medicare program that is eligible for any Medicare insured patient with two or more chronic conditions. The goal of the program is to help navigate the small details of living with and managing multiple chronic conditions. This is done in a primarily non-face to face fashion with phone calls for reminders, check-ins, medication reconciliation and visit/appointment follow up. Overall, from a provider standpoint, CCM provides three things for my patients: access to care, financial savings and more likely to achieve health goals. The CCM team is available at essentially anytime for patients to call to ask questions or discuss concerns. Certainly, there will be some things that need to be discussed more with a clinic visit or a discussion with the provider, but the majority of the time a healthcare team member will be able to answer most questions. Yes, CCM does cost the patient, however, a very recent review demonstrated that folks engaged in a CCM program saved on average about 17% yearly on their healthcare expenses. I know that may seem hard to believe, but it is well established that CCM can help to minimize Emergency Department visits for patients that could get medical advice from their CCM contact or get arranged to have a clinic visit instead and even more well documented is the preventive nature of CCM. Many major exacerbations or flares of conditions can be mitigated by the process and communication of CCM. Most of us have the same couple goals when it comes to our health: we desire to live the longest, healthiest life we can, and we want to do that in a way that we are not in the hospital frequently or taking 20 medications per day. CCM can work as an extension of your provider to make those goals even more realistic.
At PCMH we are going to be changing our CCM workflow a little bit and feel this will help our patients to meet their care goals better and serve our community better. We will
be working with a group called ChartSpan. They have a team of healthcare providers that will be communicating with our patients and working closely with us here at PCMH to improve your care. Their team will contact our patients, which is directed by us providers at PCMH. Coordinating care of a single complex condition can be difficult but having to manage multiple chronic conditions or medications or even multiple specialist visits is an extremely tall task. If you have any questions about CCM or ChartSpan or you receive a phone call or message from ChartSpan please feel free to give us a call at the clinic.
