What is Chronic Care Management?

Healthcare professional using tablet

In today’s healthcare landscape, technology plays an essential role in everything from diagnosis and treatment to the management of chronic care.

Hospitals and clinics have invested heavily in modernizing their facilities and adopting new technologies, and the results have been impressive. Patients are now able to receive faster, more accurate diagnoses, and treatments can be tailored more specifically to each individual. Because of this, the patient experience continues to improve.

Chronic care management software involves a care plan that describes a patient’s health problems and goals, health providers, medications, community services they may have and prefer, and other data about their health.

It also illustrates the care needed and how that care will be maintained. The health care supplier discusses with the patient to make an agreement to sustain chronic care management.

After the patient agrees to engage in these activates, the provider will prepare the care plan; help with medication management, interact 24/7 access for preferred care needs, give help when the patient goes from one health care structure to another, review their medicines and how they are consumed, and help with other chronic care demands, all with the help of chronic care management software.

Healthcare software diagram

What is the management of chronic care?

Chronic Care Management provides an important opportunity for clients with multiple chronic needs to get services made to improve their care and outcomes. It also assists providers to manage reimbursements for these services, many of which they already provide but are not paid for.

Objectives of chronic care management

The Chronic Care Management Program has different unique goals, which help to maintain the importance of CCM such as:

  • provide patients with the best care possible;
  • keep patients out of hospital;
  • reduce the costs and inconveniences due to wasted visits to doctors, emergency rooms, labs, or hospitals.

Patients’ time and your health is valuable. CCM is there to help with healthcare preferences so that patients can get on with living and enjoying their lives.

Main problems of chronic care management

Both patient and medical care suppliers many experience some challenges in chronic care management. As the amount of chronic conditions becomes bigger in a patient, the risk of mortality, hospitalization, and medication interaction increases. Multiple chronic conditions directly contribute to disability. Clients with multiple chronic conditions usually need more extended, more in-depth, and more constant doctor’s visits than is typical for acute care.

Evolution of chronic care management

The history of CCM has changed significantly. Let’s take a look at how Chronic Care Management was created and the changes in CCM throughout the past few years in chronic care management solutions:

  • 2015: The Beginning of CCM CCM was introduced in 2015 to provide people with multiple chronic conditions optimize their health and improve their care;
  • 2017: Introduction of Complex CPT Codes – CMS’s common rule for CCM introduced CPT Code 99490;
  • 2020: Response to the COVID-19 Pandemic – the COVID-19 pandemic affected many aspects of health care;
  • 2021: Bill H.R. 4755 – thirty-five million people in the U.S. have Medicare and at least two chronic conditions;
  • 2022: Relative Value Unit (RVU) Increases – CMS regularly updates the Physician Fee Schedule (PFS), changing payment policies and rates.

It is possible to see that many changes have happened that affect the development of software for chronic care management.

What should be done in the chronic care management model?

The Chronic Care Model engages three indispensable elements of a health care system that when integrated encourage high-quality chronic disease care:

  • community resources;
  • health system;
  • self-management support.

In order to get significant improvements in the quality of care and outcome measures, attention should be paid to each of these three issues.

While chronic care management programs might look different for different providers, successful programs all essentially have at least one thing in common. Creating an effective, compliant CCM program requires practice managers, practitioners, and clinical staff to work together to identify and enroll eligible beneficiaries and then establish protocols and routines that work well for everyone.

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