(Last Updated On: December 2, 2016)

Chronic Care Management (CCM) is available for the independent professional through billing code 99490. Although these patients are not in need of assistance with activities of daily living as other chronically ill patients may be, CCM care can still beneficially impact their health. More than 40% of patients are placed at significant risk from many diseases by misunderstanding, forgetting, or ignoring healthcare advice (1). The working professional can be supported through CCM by maintaining independence, promoting safety, and setting goals based on physician direction and level of patient understanding.

 

Maintaining Independence

CCM services can help patients maintain independence by providing education on disease processes enabling them to better self-manage chronic diagnoses in between appointments. Tips and resources given by CCM coordinators should help lower the risk of:

Massachusetts General Hospital participated in a three year demonstration project to improve care and coordination of Medicare services for 2,500 high-cost beneficiaries. Care managers worked with primary care physicians to educate patients/providers and provide care/counseling. The team care approach, including extensive use of nurses in new roles, facilitated communication during transitions, effective use of electronic health records, and coordination of care across providers and sites of care. Improved care resulted in a 20% reduction in hospital admissions and a 25% reduction in emergency department visits as well as lower mortality rates (16% compared to 20% for the control group) (2).The evaluation found 7% annual savings among enrolled patients after accounting for intervention costs (2). These patients had better outcomes as a result of increased accessibility and communication to and amongst their providers, both of which are improved through Chronic Care Management programs.

 

Working Healthcare into a Busy Schedule

A diligent CCM care coordinator should emphasize health as a priority to independent patients. CCM enrolled patients that remain employed, take care of families, and have active lifestyles, may forget to follow up with their providers as scheduled and/or complete preventative health exams as directed, which could put their health at risk. Therefore these patients should receive reminders regarding routine appointments and preventative health exams.

During these scheduled appointments, patient can have immunizations and other preventative exams reviewed, ordered, and/or completed. In an article by Medicaid Health Plans of America, care coordinators assisted by identifying women missing both their mammogram and Pap screenings. They partnered with obstetrics and primary care provider sites to administer Pap smear and mammography appointments at each site (3). 3 years post implementation of this care coordination effort, the breast cancer screening rate had increased to 52.5% and cervical cancer screening rate had increased to 73.5%, demonstrating strong success of the program which produces benefits similar to Chronic Care Management (3). The above intervention showcases how CCM care should guide independent patients to have preventative screening completed as recommended and in a timely fashion. As a result, providers are able to monitor the patient allowing for early detection of problems, thereby improving overall health.

 

Setting Goals

Being that CCM patients are required to have at least two chronic conditions, independent professionals should be encouraged to recognize and better manage their conditions through goal setting. With individualized needs in mind and a healthy, trusting relationship between patients and CCM care providers, goal setting should be geared towards managing all risk factors for progression of chronic conditions to improve clinical outcomes. When goals are set, they direct attention and effort toward goal-relevant activities and away from goal-irrelevant ones (4). For example, in Chronic Care Management patients with high Body Mass Index (BMI) can be supported through weight loss goal setting activities. The National Institutes of Health reports that individuals attempting to lose weight are generally recommended to lower their weight loss expectations and set modest weight loss goals (4).

In another study by the National Institute of Diabetes and Digestive and Kidney Diseases focused on preventing diabetes, a good patient goal was set to lose at least 5 to 10 percent (10 to 20 pounds with weight of 200 pounds) of current weight. A 5 to 7 percent weight loss was shown to have a big impact on lowering the risk of diabetes in the diabetes prevention study (5).

In light of the previous statistics, goals geared towards diet/exercise and improving key lab results are just a few examples of how CCM can be impactful by tracking, adjusting, and providing incentives for the independent professional.

References
  1. The Challenge of Patient Adherence. Leslie R Martin, Summer L Williams, Kelly B Haskard, and M Robin DiMatteo. 1(3): 189–199., Riverside, CA : Dove Medical Press Limited, 2005, Vols. 1(3): 189–199. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/.
  2. John Holahan, Cathy Schoen, and Stacey McMorrow. The Potential Savings from Enhanced Chronic Care Management Policies. s.l. : The Urban Institute Health Policy Center, 2011. http://research.urban.org/uploadedpdf/412453-The-Potential-Savings-from-Enhanced-Chronic-Care-Management-Policies-Brief.pdf.
  3. Liza Greenberg, RN, MPH, MHPA Senior Consultant, Clinical Initiatives. Treatment Adherence Best Practices Compendium . Washington, DC : Medicaid Health Plans of America, Merck and Co, 2012. URL: http://www.mhpa.org/_upload/adherencecompendiumweb2.pdf.
  4. Ain’t no mountain high enough? Setting high weight loss goals predict effort and short-term weight loss. Emely De Vet, Rob MA Nelissen, Marcel Zeelenberg. s.l. : sagepub.co.uk/journalsPermissions.nav. 10.1177/1359105312454038.
  5. The National Institute of Diabetes and Digestive and Kidney Diseases. The National Institute of Diabetes and Digestive and Kidney Diseases. [Online] [Cited: August 30, 2016.] https://www.niddk.nih.gov/health-information/health-communication-programs/ndep/am-i-at-risk/take-small-steps/set-weightloss-goal/Pages/weightlossgoal.aspx.