As of January 2015, Chronic Care Management (99490) is billed with the requirement of electronic medical record access. The Centers for Disease Control and Prevention reports that over 70 percent of office-based physicians utilize a certified electronic medical record (1). However, proper Chronic Care Management often takes more than just an electronic health/medical record (EHR/EMR) – robust CCM requires a care coordination platform that can assist a coordinator in managing multiple patients across the full continuum of care. Chronic Care Management coordinators should utilize a care coordination platform along with the EHR, promote the use of assistive technologies, and track CCM patients via patient monitoring devices.
Care Coordination Platform
Individualized Chronic Care Management care plans, are best created in a care coordination platform geared towards rapidly charting a disease-specific pathway for a chronically ill patient. This platform also should be able to address the patient’s social concerns (e.g. financial strains of food, utilities, medication, or transportation). Among physicians with a certified electronic medical record system, 14 percent shared patient health information electronically with behavioral health providers, 13.6 percent with long-term care providers, and 15.2 percent with home health providers (1). Chronic Care Management team members should use the care coordination platform to easily share critical pieces of information from the EHR among the care team such as the following:
- Lab results
- Physician notes
- Health histories
- Discharge summaries
- Immunization records
- Medication lists
Based upon the above, CCM patients will benefit from improved communication between providers, especially around medication reconciliation. CCM Coordinators should also be able to use the platform/EHR to quickly respond to patients in between provider appointments, increasing patient touchpoints and improving overall disease management.
Assistive technologies consist of various equipment and devices that help Chronic Care Management patients perform tasks or prevent injuries (2). The National Council on Aging says that at least 30% of older adults (i.e., people aged >65 years) living in the community fall each year, and the likelihood of falling increases rapidly with advancing age (3). Traditional home environment items such as grab bars, wheelchairs, or canes are of benefit for CCM participants, but additional assistance technologies (e.g. hearing aids, digital watches, medication reminder systems, and medical alert systems) serve patients as well. CCM coordinators can help patients and caregivers locate and compare assistive technology options to improve the patient’s safety at home. CCM patients using assistive technology could see a reduction in risky behaviors such as:
- Forgotten medications
- Forgotten appointments
- Fall occurrences
Through use of assistive technologies (often via mobile devices), Chronic Care Management patients should be able to live more safely and independently in their own home.
Patient Monitoring Devices
Patient monitoring devices include a wide variety of technologies designed to manage and monitor a range of health conditions (2). CCM coordinators should provide patients with information regarding home monitoring devices such as blood pressure monitors, glucometers, and weight scales. Remote monitoring allows coordinators to better track progress against Chronic Care Management care plan goals and encourage accountability. For instance, a coordinator may help Chronic Care Management patients with diabetes complete the following steps:
- Obtain an order for a glucometer
- Receive test strips from a pharmacy
- Use a glucometer correctly
- Report recurring blood glucose level below 60 to provider
- Recognize signs of hypoglycemia
- Initiate change in medication per provider instructions
- Record blood glucose level daily or weekly in a mobile application
- Review levels and track against CCM care plan goals
- Schedule follow up appointment with endocrinologist including presentation of tracked data
Coordinators and providers should see improvements of CCM patient’s lab results, lifestyles and overall health as a result of the use of technology to supplement Chronic Care Management.
- Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. [Online] US Department of Health and Human Services, January 27, 2016. [Cited: September 19, 2016.] http://www.cdc.gov/nchs/data/databriefs/db236.htm.
- Center for Aging and Technology, Technologies to Help Older Adults Maintain Independence. www.techandaging.org. [Online] July 2009. [Cited: September 20, 2016.] http://www.techandaging.org/briefingpaper.pdf.