According to the Centers for Disease Control and Prevention (CDC), roughly 6 in 10 adults in America are living with at least one chronic condition. The CDC defines these as “conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both.” This definition underscores the need for effective management of chronic conditions—primarily, so patients can live long, satisfying, and productive lives.
Chronic care management (CCM) is a set of practices that help those living with chronic conditions to better understand their conditions and how to mitigate their effects. In other words, it enables them (and their caregivers) to make the best lifestyle choices and treatment decisions to improve their short- and long-term quality of life.
In this blog, we’re taking a high-level look at chronic care management, including topics like:
- What chronic care management entails, why it’s important, and who qualifies.
- The impact of chronic care management solutions on patients and healthcare providers.
- How TimeDoc Health empowers patients and caregivers with a better chronic care management experience.
What Is Chronic Care Management?
According to the Centers for Medicare & Medicaid Services (CMS), chronic care management refers to “care coordination services done outside of the regular office visit for patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient.” These parameters help to ensure that those with the greatest need for CCM solutions can access care and support when they need it the most.
What Conditions Qualify for Chronic Care Management?
Chronic conditions that can benefit from chronic care management include:
- Alzheimer’s Disease, the 7th leading cause of death in the U.S.
- Cancer, the 2nd leading cause of death in the U.S.
- Chronic Kidney Disease, the 8th leading cause of death in the U.S.
- Chronic Lung Disease, the 6th leading cause of death in the U.S.
- Diabetes, the 8th leading cause of death in the U.S.
- Heart Disease, the leading cause of death in the U.S.
- Stroke, the 5th leading cause of death in the U.S.
What Are Examples of Chronic Care Management Services?
A few examples of CCM services include:
- Engaging with patients in between scheduled visits (via telephone or secure email, for example).
- Providing patients with recommendations for lifestyle changes that could alleviate certain conditions or their symptoms.
- Educating patients about the conditions they’re experiencing, including what factors might contribute to them or how they can prevent them from getting worse.
- Enabling opportunities for finding urgent or emergency care 24/7.
- Coordination between different healthcare providers—including pharmacists and specialists—so everyone is working from a single playbook.
- Exploring opportunities for home- or community-based services, making healthcare more accessible.
What Does a Chronic Care Management Plan Look Like?
To illustrate how the different components of chronic care management go together to create a streamlined and proactive approach to patient care, consider the following example:
Let’s say a patient named Sally D. has recently been diagnosed with type 2 diabetes. Her healthcare provider introduces her to the importance of understanding her condition, managing her symptoms, and monitoring any developments over time. This essential patient education lays the framework for Sally’s chronic care management plan.
Sally’s healthcare provider then educates her about the types of self-monitoring and symptom management she can perform herself over time, with recommendations including:
- Maintaining blood glucose logs to monitor her condition.
- Setting lifestyle goals such as improving her diet and trying to exercise regularly.
- Taking the proper medications, as prescribed.
- Procuring glucometers, compression stockings, and other items related to the management of diabetic symptoms.
These recommendations empower the patient to monitor her own condition, reducing the need for frequent appointments. As part of this chronic care management plan example, the patient would also receive specific guidance about contacting their healthcare professional with any questions or concerns, as they develop.
Why Is CCM Important?
CCM is important because it makes proactive and ongoing healthcare much more effective for those living with chronic conditions. It enables their providers to better understand patient health from a more comprehensive and actionable standpoint, creating more efficient and effective healthcare.
Chronic care management is important, in short, because it can improve the timeliness and overall quality of care a patient receives. A well-developed chronic care management program also…
- Empowers patients with a better understanding of their condition(s)—and how they can take proactive or lifestyle-related measures to improve their quality of life.
- Enables healthcare providers to coordinate with each other, in order to deliver more efficient, effective, and well-rounded healthcare.
What Are the Benefits of CCM?
Chronic care management benefits patients as well as healthcare providers in a number of ways, which we’ll explore next.
What Is the Impact of CCM for Healthcare Professionals?
Well-designed chronic care management services provide a number of compelling benefits for healthcare professionals. These center around the ability to deliver more timely and well-rounded care options to improve patients’ quality of life through improved communication and alignment between healthcare providers and their patients.
CCM best practices also help healthcare providers to improve their internal processes and workflows within the healthcare system, increasing the efficiency and effectiveness of different courses of treatment. This includes making it easier for healthcare organizations to comply with Medicare/Medicaid billing requirements (such as CCM billing guidelines for 2023) and improve their overall documentation processes, as well.
How Does Chronic Care Management Help Patients?
Chronic care management benefits patients with chronic conditions by helping them…
- Receive healthcare services that are timely and effective—including touchpoints or support in between their appointments.
- Learn about their health, so they can better understand how to manage their conditions, take more control over their well-being, and live fuller, healthier lives.
- Reduce costs associated with patient care, by empowering patients with resources and support for health management and care. This helps them to make lifestyle changes or pursue treatment options that can prevent more serious conditions from developing or progressing.
TimeDoc: Chronic Care Management, Reimagined
Effective chronic care management is both an art and a science—
- The science is that of understanding chronic conditions, their causes, and treatment options.
- The art involves working with patients in a well-rounded and easy-to-understand manner.
TimeDoc Health represents a unique and comprehensive approach to chronic care management, one that addresses the art as well as the science.
- Healthcare providers can use the TimeDoc platform to provide care options in between scheduled appointments, customize treatment plans and timelines, and help ensure patients remain on track throughout their course of care. Learn more about TimeDoc’s chronic care management offerings.
- TimeDoc Health also has a team of care coordinators to help develop and organize treatment plans and ensure that patients can receive the right care at the right time. Learn more about how it works.
You can learn more about TimeDoc here. When you’re ready to see the platform in action, just click the Request demo button on our website to take the first step!