(Last Updated On: December 2, 2016)

Coordinators should motivate Chronic Care Management patients through consistent support. Education and increased communication through Chronic Care Management coordinators should give patients better ways to manage their health. These benefits should lead to increased levels of compliance and trust among Chronic Care Management patients. Patients enrolled in Chronic Care Management billed by CPT code 99490, should receive chronic condition information, relevant goal setting, and encouragement to express clinical and social needs.

More Chronic Condition Information, More Motivation

Coordinators should provide patient-friendly teaching regarding Chronic Care Management patients’ health concerns. People 65 and older make nearly twice as many physician office visits per year than adults 45 to 65 (1). However, an estimated two-thirds of older people are unable to understand the information given to them about their prescription medications (1). Promoting Chronic Care Management patient literacy impacts proactive self-management of chronic conditions and health improvement. CCM recipients should benefit from various methods of patient education such as:

  • Gaining access to pertinent reference material (e.g. videos, classes, books, and groups)
  • Incorporating teach-back methods to information provided
  • Referencing all providers’ instructions

The use of wide-range motivation and education efforts, much like the previous, should provide Chronic Care Management participants necessity information to impact their care.

Chronic Care Management Embraces Targeted Goal Setting

Relevant goals are set for Chronic Care Management patients based upon specific provider instructions and patient interests. Examples of goals targeted as a result of patient-coordinator Chronic Care Management communication include:

  • Lose 30 pounds in 3 months
  • Walk 30 minutes every other day
  • Take only 2 blood pressure medications by the end of the year
  • Eat 3-5 small meals per day
  • Sleep at least 8 hours each night
  • Meditate for 15 minutes twice a day
  • Drink 8 glasses of water each day
  • See primary care provider every 6 months

The prior mentioned goals, allow Chronic Care Management patients to make improvements in their health. Supportive coordinators should assist CCM patients with tracking their goals and motivating each patient by noting achievements and efforts. Goal attainment is beneficial to overall physical wellbeing; it elicits positive emotions such as pride and joy. Embracing motivation and relevant goal setting/tracking, leads to maximized participation in Chronic Care Management.

Coordinators Encourage Chronic Care Management Patients to Express Clinical and Social Needs

Motivation from Chronic Care Management team members allows recipients to obtain resources according to their individual clinical and social needs.  Coordinators should meet patient needs, avoid further accumulation of expenses (e.g., medication costs, medical supplies), maintain open communication with providers, and promote better quality of life (2).The following list entails potential assistance Chronic Care Management recipients may encounter:

  • Assistive device access
  • Transportation assistance
  • Medication cost cuts
  • Food supplement resources
  • Housing application assistance
  • Pharmacy communication

In addition to the assistance options listed, coordinators should assess for other ways to help Chronic Care Management recipients. Approximately, 6.8 million community-resident Americans use assistive devices to help them with mobility (3).  Four-fifths of wheelchair users report that their local public transportation system is difficult to use or to get to (3). Chronic Care Management’s open provision of information, targeted goal setting, and addressment of clinical/social needs builds trusting relationships and creates objective dialogues among patients, caregivers, and providers, thereby increasing motivation for Chronic Care Management patients to better manage their chronic conditions.

 

References
  1. National Network of Libraries of Medicine . Health Literacy. [Online] US National Library of Medicine. [Cited: September 13, 2016.] https://nnlm.gov/outreach/consumer/hlthlit.html.
  2. BioMed Central. [Online] BioMed Central Ltd, 2016. [Cited: September 16, 2016.] http://hqlo.biomedcentral.com/articles/10.1186/1477-7525-2-32.
  3. Center, The University of California – Disability Statistics. Disabled World. [Online] Disabled World, 2004-2016. [Cited: September 20, 2016.] http://www.disabled-world.com/disability/statistics/mobility-stats.php.