If you’re wondering what defines a chronic health condition, it’s a serious mental or physical illness where symptoms last one year or longer. These conditions include heart disease, cancer, diabetes, depression, substance use, and chronic lung disease, among many others. These conditions require ongoing care and often negatively impact a person’s quality of life.
In the U.S., 6 in 10 adults have a chronic disease. What’s more, 4 in 10 adults have 2 or more chronic diseases. To address these conditions and improve patients’ daily lives, many care teams are implementing something called “chronic care management.”
Why? In a study of programs using multidisciplinary care teams and in-person communication methods, this approach decreased readmissions by 60%. It also led to a 50% decrease in the number of readmission days per month.
With that in mind, keep reading to learn how you can implement chronic care management in your organization and how to deliver it effectively.
Chronic care management definition
Chronic diseases are complicated. They typically impact multiple organs and body systems, requiring an integrative approach to care. These chronic conditions often require multiple clinicians, healthcare facilities, and home-based care.
Chronic care management is defined as a care management service and has been covered by the Centers for Medicare & Medicaid Services (CMS) since 2015. Specifically, it allows patients with 2 or more chronic conditions to enter into an ongoing, 24/7 relationship with their care team.
This service enables clinicians to make more frequent contact with patients who are suffering from chronic illness — providing additional touchpoints in between traditional in-office visits. It includes a comprehensive care plan that is agreed upon by both the clinician and the patient. This plan must also include remote communication, medication management, and care coordination between primary care providers and specialists.
Moving away from “episodic” care
Strep throat, a sprained ankle, an annual gynecological exam — these are examples of episodic (or acute) events. Not much follow-up is required and that’s fine … for this kind of care. Too often in today’s broken system, however, this is the model that’s followed for everyone. Hospitals are repair shops, treating patients quickly. Primary care handles maintenance visits like physicals or short-term, easily resolved complaints. But what about those patients who require regular interventions?
Those approaches are the very opposite of what’s needed if you depend on support like daily monitoring or constant adjustment to a treatment plan. Six months between visits won’t work — patients can’t go it alone and there’s no real opportunity to jump in early to make a difference when there’s a problem. That’s why a care team model is so much more effective: it’s specifically designed to utilize a greater number of people to stay in close coordination with the patient and each other.
Who qualifies for chronic care management?
Both patients and providers benefit from this approach to care, but they must meet certain eligibility requirements. Healthcare professionals must be aware of billing codes and eligibility. Patients must be evaluated for eligibility, be educated so that they understand their care plan, and give their consent to be entered into such a program.
Which clinicians qualify?
Chronic care management services can be provided by a clinical staff person, but services must be billed under:
- Physician assistants (PAs)
- Nurse practitioners (NPs)
- Clinical nurse specialists (CNSs)
- Certified nurse-midwives (CNMs)
- Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
- Hospitals, including Critical Access Hospitals (CAHs)
Note that only one clinician, RHC, or FQHC, and one hospital, can bill for these services for a single patient during a calendar month.
Which patients qualify?
Patients may be eligible for chronic care management if they have 2 or more chronic conditions. This includes but is not limited to:
- Alzheimer’s disease and related dementia
- Arthritis (osteoarthritis and rheumatoid)
- Atrial fibrillation
- Autism spectrum disorder
- Cardiovascular disease
- Chronic obstructive pulmonary disease (COPD)
- Infectious diseases such as HIV/AIDS
- Multiple sclerosis
- Substance use disorders (SUDs)
An additional qualifying step is that patients must give their consent to be entered into such a program. They need to understand that they can stop the program at any time. They also must agree that only one health professional will be providing these services — they cannot enter into a program with more than one clinician at a time.
How to deliver effective chronic care management
The Wagner chronic care model has been widely used to measure the efficacy of programs. This model identifies 6 areas for effective interventions:
1. Improved support for patients’ self-management
2. Well-designed delivery of care
3. Increased access to expertise and decision support
4. Wider availability of clinical information
5. Organized practice systems and provider roles
6. Community support
These 6 areas can be applied to a variety of chronic health conditions, clinical settings, and patient populations. Explore each area below and learn how to integrate it into your care delivery.
First, patients in chronic care management programs must be engaged, active participants in their care plans. As mentioned previously, patients must give their consent before entering into the program. Therefore, they must not only understand their chronic conditions but also understand the program itself.
To support patient self-management, clinicians must educate patients with the goal of achieving buy-in. When patients understand their diagnosis and care plan, they can collaborate to set achievable goals. Note that clinicians should practice whole-person care, treating the mind, body, and spirit in alignment with cultural considerations and patient preferences. Without this approach, you may miss opportunities to engage a patient’s caregivers and support network.
Design efficient care delivery systems
Now that patients are engaged, you need to ensure that every member of your multidisciplinary care team is on the same page.
Communication is key. Clinicians, whether in primary or specialty care, and support staff must have a reliable source of up-to-date information. They also must have a clear understanding of the roles each member of the patient’s care team will play.
This is where a Care Management platform comes in. With the tools they need to coordinate and automate care plans, your team can easily hand off patients to other team members as needed. These platforms can streamline communication, centralizing conversations so they’re in the know at all times. Plus, patients gain peace of mind knowing that they can reach their care team, get the answers to their questions, and never miss an important message.
Support provider decision-making
Next, it’s important that your care teams are empowered with the information they need to provide high-quality care. Clinicians need recurring training, continuing education, and clinical guidelines — as well as access to the latest research, treatments, and techniques.
With clinical decision support (CDS), clinicians receive timely, relevant information to assist them in making informed decisions for patients. They’re able to integrate evidence-based guidelines into their patient recommendations. They can even be notified of dangerous health situations or when it’s time for preventive care.
It’s no wonder then that CDS has been found to improve patients’ health outcomes and increase quality of care. In fact, it also can lead to fewer errors, lower costs, and higher efficiency. By implementing a chronic care management program, you can be sure that CDS is on hand when and where care teams need it most.
Invest in quality health information systems
When it comes to health information technology (IT), it can either help or harm your care team’s ability to deliver quality care. When managing chronic illness, health IT is even more important. Without a system to track clinician roles, communication, and patient progress, you won’t be able to see how all elements of a care plan are integrated.
Plus, while electronic health records (EHRs) are frequently used by care teams, they were designed for billing purposes. EHRs do not put clinical teams first — they actually contribute to clinician burnout. In fact, one study found that 70% of physicians say the bulk of their administrative burden comes from EHR use.
By removing this burden, clinicians are able to increase their face-to-face time with a patient. Their documentation compliance may increase as clinicians’ click fatigue and screen time is reduced. With a Care Management platform, clinicians can establish clear workflows, better navigate transitional care, and easily provide feedback to other members of a patient’s care team.
Get organizational buy-in
Next, you’ll want to ensure buy-in from the entire organization. Without it, you’ll face obstacles such as care team members not understanding the motivation or need for such a program. Likewise, senior management must believe in the importance of the program in order to update the organization’s policies, technology, and procedures.
Where do you start? Ask for support from your organization’s board of directors early — and keep them updated by
sharing the results. You want senior leadership and staff to support and promote improvements at every level of the organization to increase its visibility.
For example, leadership can discuss the program in all-staff meetings. They can assist with goal-setting activities and provide guidance to clinical teams. They can provide feedback to the board on a regular basis to increase awareness and make a clear connection between leadership support and improved outcomes.
Leadership can also get a multidisciplinary group of care team members to test new platforms and software. They can ask for data and align the team on how this data is to be used. They can empower team members to own their part of chronic care programs by allowing them to present their improvements and outcomes. And, they can ensure the patient experience remains top of mind by sharing feedback and case studies as improvement efforts are implemented.
Integrate community support
Last, but certainly not least, to implement effective chronic care management, it’s important to remember the value of community support. While an individual may be a patient to your care team, they are also a family member, friend, coworker, and community member. They’re surrounded by others who influence their health and wellness — and who can be positive, proactive guides.
Be sure to identify organizations that can support your patient’s entire health journey. These can be community programs, churches, civic groups, state agencies, local advocacy groups, and alternative care providers. Encourage as many interested stakeholders in the patient’s life as possible to get involved so you can improve the patient’s engagement and care plan compliance.
These community partnerships can also assist in improving population health. Ask for feedback on your program, and you’ll also help these organizations understand and adapt to the wide range of chronic care needs. Share your pain points, and they may be able to recommend other venues or partners who can assist you. Seek out partnerships to fill a gap in care, and you’ll be able to represent your patients by sharing their perspectives with community leaders.
Want to upgrade your Care Management?
Now that you understand chronic care management, which patients and providers are eligible, and how to deliver it effectively, it’s time to take the leap toward implementing it in your organization.
It’ll be no surprise to you that Care Management programs reduce the need for healthcare services and improve health outcomes, particularly for patients with chronic conditions. Read the Welkin Health guide to Care Management to learn more about Care Management strategies.