Person is talking on the phone while writing in a notebook

What Is the Purpose of Chronic Care Management?

According to the National Association of Chronic Disease Directors, over two-thirds of all deaths in the United States are caused by complications related to one or more of five chronic diseases: 

  1. Heart disease
  2. Cancer
  3. Stroke
  4. Chronic obstructive pulmonary disease
  5. Diabetes

The core purpose of chronic care management (CCM) is to help physicians monitor and treat chronic conditions effectively and ensure that patients are supported when navigating the complex healthcare system. CCM initiatives are designed to consider all complications brought on by chronic conditions, as well as external factors that impact a patient’s health. As patients onboard, care providers assess all possible challenges and develop a unique care plan to ensure all patient needs are met. Sounds pretty straightforward, right?

Unfortunately, it’s not. 

It’s well known that conventional CCM approaches possess significant shortcomings related to the overall care processes. Although it is clear that CCM works in theory, successful execution is much more nuanced. Currently, physicians are held back by many significant challenges, including:

  • Limited resources and staff
  • Constricted time-frames
  • Budget constraints

Each of these hurdles hinder health professionals’ ability to launch and sustain profitable CCM programs that truly deliver. So, how can the healthcare system make CCM work the way it is supposed to? To provide sustainable, flexible, and cost-effective care for chronic conditions, healthcare officials can lean on innovative tech-enabled CCM services for the ongoing treatment of chronic conditions. 

In this blog, TimeDoc will dive into the intricacies of CCM and how a comprehensive CCM solution eliminates some of these common challenges. 

What Does Chronic Care Management Include?

A typical CCM model creates a framework for healthcare teams to develop individual care plans. These plans encompass many health objectives including: keeping track of a patient’s health problems and goals, monitoring the patient’s progress, and recording all aspects of the patient’s treatment plan. 

Put simply, a CCM plan outlines the specific care a patient needs and how providers will coordinate it.  Here are some examples of different duties executed throughout CCM.

  • Care coordination is where a patient’s healthcare team begins to create a comprehensive care plan. This plan considers the patient’s medical history, current health status, individual needs, and unique preferences. 
  • Remote follow-up meetings are regularly scheduled telemedicine check-ins where a care team connects with patients to assess their health status. Pending the outcome of each discussion, the care team will choose to make certain adjustments to the patient’s care plan. The purpose of these meetings is to ensure that every patient receives optimal care and support between appointments. 
  • Patient education is meant to help chronically ill people navigate the complex world of healthcare. Throughout ongoing follow-up calls, the care team works with patients to provide additional education to help patients better understand their condition and formulate strategies to manage their symptoms.
  • Medication management is where care teams monitor all aspects of chronically ill patients’s complex medication regimen. As a part of the CCM process, the care team will ensure that patients take the correct dosage at the appropriate times, help the patient monitor for potential side effects or drug interactions, and make ongoing adjustments based on how the patient reacts.
  • Remote monitoring allows the care team to monitor a patient without adding additional in-person visits. To make this process function smoothly, patients wear monitoring devices so the care team can monitor the patient’s condition in real-time. Remote patient monitoring is critical for identifying potential issues before acute health episodes occur. 

How Do CCM Platforms Enhance the Chronic Care Management Process? 

Managing patient data, keeping up with billing, scheduling various appointments, and creating effective care plans is a lot of work. And juggling all of these processes places a significant strain on care teams. Thankfully, all of this can be managed using a CCM platform. 

Take TimeDoc Health, for example. The TimeDoc platform automates various aspects of the care planning process, and streamlines the documentation and billing process to give care teams more time to focus on what matters. Additionally, one of the most critical failures in the CCM process is limited and inconsistent communication between stakeholders. A CCM platform like TimeDoc, when integrated in your EHR, standardizes and improves access to data for physicians and other clinicians involved in the treatment process. 

At a glance, TimeDoc’s CCM platform facilitates information sharing within care teams, supports ongoing patient care, and makes it possible to monitor adherence to treatment regimens. With this high-level support, care teams limit hospitalizations, improve the patient experience, and achieve optimal health outcomes.

But what about the personal side of things? Alongside our platform, TimeDoc provides staff augmentation services, to ensure patients receive the constant contact they need without putting additional strain on physicians and their teams. TimeDoc gives our partners access to a dedicated team of clinical care coordinators who personalize care for each of your patients. Learn more about our solution here.

What Conditions Qualify for Chronic Care Management? 

According to the CMS chronic care management guidelines, eligible CCM patients have “multiple (two or more) chronic conditions expected to last at least 12 months or until the patient’s death and or that place them at significant risk of death, acute exacerbation and or decompensation, or functional decline.” Individuals with diabetes, cancer, and Alzheimers are excellent candidates for CCM. So, how does a CCM solution like TimeDoc fit in?

A CCM platform is able to help care teams manage each person’s complex medical regimen and adapt to their unique life circumstances. For example, using TimeDoc’s CCM platform and services, a diabetic patient was able to address an urgent issue with their medication. During a telehealth follow-up meeting with a TimeDoc care coordinator, the patient mentioned that their new insulin had not arrived yet. 

Although the patient did not feel well, they hesitated to take the 50/50 insulin they had available. The care coordinator immediately contacted endocrinology to confirm that the patient could safely use the 50/50 insulin. The care coordinator also created automatic refills to be sent directly to the patient. Without TimeDoc, this process would have been much more cumbersome and time-consuming. And when dealing with chronic illness, a fast and efficient response to a problem can mean the difference between life and death. Read more patient success stories here

Revitalize Your Chronic Care Management Program With TimeDoc Health

As the prevalence of chronic illnesses continues to climb, the need for improved CCM is even more urgent. According to one report, chronic diseases will affect approximately 164 million Americans—nearly half (49%) of the population—by 2025. In short, time is of the essence, and healthcare teams need all the help they can get. 

Whether you're just starting to build a CCM program or want to improve what you already have, TimeDoc Health is here to support you and your patients. Our platform and care management services make it simple to engage with patients, stay in the loop regarding patient health statuses, deliver valuable health education, and much more. See what TimeDoc can do for you and request a demo today.