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What Does the Chronic Care Model Do?

Chronic care management (CCM) is essential for patients with long term conditions to help manage their treatment. But what is the chronic care model and how does it work? The model is a foundation that helps CCM professionals and patients work together to provide the best medical care to those with two or more chronic conditions. In this blog, we example the model in detail, so you can be informed about CCM solutions and how you can implement them.

What Is a Chronic Care Management Model?

The chronic care model is the preferred framework by healthcare providers for planning and delivering treatment for patients with chronic diseases. In general, it outlines the key aspects of a healthcare system that supports high-quality chronic illness care. Based on this model, treatment is given in a primary care setting using a strategy that combines patient, provider, and system interventions. This is required to achieve the overall objective of improving chronic disease care for patients. The chronic care model framework focuses on providing proactive, population-based treatment. 

As a part of this model, chronic care management involves care coordination services, which are offered to patients who have two or more chronic conditions. CCM outlines the type of care you require and how your providers will organize it. To be considered chronic, an illness or condition lasts for a year or more, needs continuing medical care, or restricts everyday activities. For example, both physical and mental illnesses, such as diabetes and depression, qualify as chronic conditions. With that in mind, CCM aims to help patients:

  • Create a thorough care plan
  • Manage remote communication
  • Manage medications
  • Coordinate care between providers 

What Is the Goal of the Chronic Care Model?

The chronic care model is a patient-centered plan with the goal of organizing and improving care for individuals with chronic conditions. It is ultimately based on the belief that people who suffer from chronic conditions should be given access to ongoing assistance and care. To achieve this, the chronic care model focuses on:

  • Educating and equipping patients to take charge of their own health and medical treatment.
  • Ensuring that clinical treatment is delivered effectively, efficiently, and with support for self-management.
  • Organizing patient and demographic data in order to provide more efficient and effective treatment.
  • Encouraging clinical treatment that is in line with available data from science and patient preferences.

The model is utilized to improve the use of current resources, develop new resources, and promote a new approach to communication from providers to patients. Communication with patients should help them be more informed, empowered, and proactive with their healthcare.

What Are the 6 Elements of the Chronic Care Model?

To break down the model even further, the six chronic care model components are:

  • Health System/Organizational Support: Effective chronic condition care requires a well-managed and structured health care system. This involves creating specialized teams of physicians who are in charge of treating patients and providing resources to personnel.
  • Self-Management Support: Patients with chronic diseases can control their health plans and be more engaged in their care with self-management. It can be more effective and less expensive to provide patients with information and services to assist them in managing their conditions.
  • Community: The treatment provided to patients with chronic diseases by a health system might be reinforced or helped by community programs and organizations. Healthcare institutions should form collaborative relationships with state programs, local agencies, schools, faith-based organizations, and local companies.
  • Delivery System Design: This element consists of scheduled visits that give priority to the patient's goals. A delivery system helps to maintain their health and make better use of available medical resources. The care teams also make sure that there are frequent follow-ups to make sure the patients understand and accept the treatment they get.
  • Decision Support: Giving providers the data they need to make treatment recommendations, as well as assisting patients in understanding their alternatives is essential in CCM. This is important so they can make well-informed healthcare decisions. Decision support makes it possible for physicians to provide care in accordance with patient preferences and scientific evidence.
  • Clinical Information Systems: These systems help medical personnel keep track of patients' progress and spot potential problems early so they may take action before the situation escalates. Also, clinical information systems make it possible for quick and easy information sharing across providers, which improves collaboration and teamwork.

An effective chronic care model should emphasize the patient's key responsibility in their own health management. This should result in the development of evidence-based recommendations and sharing of knowledge by providers in order to encourage patient engagement. However, it’s important for providers to integrate their expertise into the plans they develop with their patients and get involved in their communities. As a provider, you can collaborate with neighborhood organizations to encourage the development of solutions that address gaps in community resources and other services.

Why Is Chronic Care Management Important?

CCM is an important part of healthcare, because it improves patient outcomes. Using CCM, providers are able to help their patients manage their illnesses or conditions in a safe and effective way. To do this for your patients, you should consider offering CCM services. Sharing patient data, fostering easier care transitions, and keeping track of prescriptions are all made possible by CCM. CCM services also help your hospital generate more income, improve Medicare compliance, and optimize your care management systems. 

CCM solutions like TimeDoc provide simple chronic care management programs that are directly connected to medical providers' electronic health information (EHR). In order to deliver the best quality patient care possible, our cutting-edge solution offers an easy-to-use platform that enables provider teams to effortlessly maintain patient profiles, identify high-risk patients, and create metric-based reporting. If you’d like to learn more about how TimeDoc can help you, visit our website to request a demo.