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The Importance of Comprehensive Care Plans as Part of a Successful Chronic Care Management Program

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Chronic diseases are one of the costliest challenges facing our US healthcare system, accounting for 90% of the nation’s $4.1 trillion in annual healthcare expenditures. But the good news is that the early detection and management of chronic diseases can lead to fewer complications, better health outcomes for patients and lower care costs.

What’s more, is that a successful chronic care management (CCM) program can help medical practices and healthcare organizations lower costs by prioritizing preventative care and empowering those with chronic conditions to live their healthiest lives.

What is CCM?

CCM refers to the ongoing management of patients with chronic medical conditions, such as diabetes, heart disease, and cancer. CCM aims to improve the quality of care and health outcomes for patients with chronic conditions by providing comprehensive, coordinated, and personalized care services. This may include regular check-ins, medication management, care planning, and patient education to help manage their health and prevent complications.

According to the Centers for Medicare and Medicaid Services (CMS), there are certain requirements that must be met to participate in CCM. Some of the key requirements include the following:

  1. Patient Eligibility: The patient should have at least two or more chronic conditions that are expected to last for at least 12 months.
  2. Consent: The patient must provide a written consent form agreeing to receive CCM services. The consent should also include the management of the patient’s chronic conditions and the use of electronic health records (EHRs).
  3. Minimum Time Requirement: Care management services must be provided for at least 20 minutes per month by clinical staff, including registered nurses, licensed practical nurses, medical assistants, and others.
  4. Comprehensive Care Plan: The care plan should be comprehensive and include all the patient’s chronic conditions, medications, allergies, and other health considerations.
  5. Care Coordination: Care coordination involves the management of the patient’s care across different providers and settings.
  6. Use of EHRs: The patient’s EHR must be used to provide care management services and document the care provided.

Some examples of care services provided through CCM may include the following:

  • Sending reminders to patients for their preventive services, such as annual wellness exams, mammograms, screenings, and vaccines.
  • Working with patients to discuss and educate them on a healthy diet and eating habits.
  • Reviewing readings from remote physiologic monitoring (RPM) to ensure metrics are within range.
  • Sharing information with patients to assist them in quitting smoking.
  • Coordinating the CCM program by assisting with information sharing among providers.
  • Carrying out medication reconciliation and updating providers if changes or refills are required.
  • Identifying if a patient needs any qualified medical equipment such as a wheelchair or walker.

What is a CCM care plan?

A CCM care plan is a comprehensive care plan for all patient health issues with a focus on managing their chronic conditions. The care plan is a requirement of a CCM program and includes the patient’s health problems and goals, medications, and other information about a patient’s health.

The purpose of the care plan is to create a coordinated approach for managing the ongoing care of patients with multiple chronic conditions. It acts as a roadmap that outlines personalized healthcare goals, treatment plans, and interventions. In addition, the care plan serves as a guide for the care team involved in the patient’s care, ensuring that everyone is on the same page regarding the patient’s medical history, current conditions, and treatment plans. It also helps to evaluate the effectiveness of the program by regularly monitoring and adjusting the care plan based on the patient’s response to treatment.

Who should create the CCM care plan?

In general, CCM care plans are the responsibility of licensed clinical staff members who are under the oversight of the patient’s physician. These clinical staff members may include LPNs, RNs, MAs, PAs, NPs, and LCSWs.

Who should have access to a patient’s CCM care plan?

A CCM care plan should be available to all providers within the practice and can be shared with any clinical staff outside of the practice who work with the patient.

What does a CCM care plan include?

According to CMS, a comprehensive care plan typically includes, but isn’t limited to:

  • Problem list—including patient’s chronic conditions, medications, and allergies
  • Expected outcome and prognosis
  • Measurable treatment goals—identification of the patient’s health goals and priorities.
  • Patient education on self-management, including lifestyle changes and disease management
  • A cognitive and functional assessment
  • Symptom management
  • Planned interventions
  • Medication management plan—including patient’s prescription medications and supplements
  • Environmental evaluation
  • Caregiver assessment
  • Coordination of care among all healthcare providers involved in the patient’s care
  • Requirements for periodic review of the care plan and adjustments made as needed
  • When applicable, revision of the care plan

The specific elements of a CCM care plan may vary depending on the patient’s individual needs and medical conditions.

Why is a CCM care plan important?

A Chronic Care Management care plan is crucial to closing gaps in care, especially when the patient has multiple chronic conditions and different providers involved in their care. With a comprehensive care plan, all healthcare providers are made aware of new changes in the patient’s health information, enabling better communication and coordination of care. In addition, patients receive guidance, education, and support, making them more likely to be adherent, resulting in better health outcomes and quality of life.

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