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
Goals 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.
The Six Components of the Chronic Care Model
One of the reasons CCM is supported by Medicare is because of the ample evidence that this model significantly improves patient outcomes. The model for chronic care management itself has been developed over the last several decades. This model takes a broad view of CCM management, and considers all the elements that influence a patient’s ability to manage their condition, including:
- The Community
- The Health System
- Self-Managed Support
- Delivery System Design
- Decision Support
- Clinical Information Systems
Let’s take a closer look at how each of these components can improve patient health and reduce overall healthcare costs.
The Community
The communities where patients live have a large effect on their day-to-day lives, and influence their health outcomes. Community resources like libraries, schools, non-profits, and faith-based organizations can all provide support to people with chronic health conditions. All these community groups can:
- Fill gaps in the care patients need, like regular check-ins and transportation to appointments
- Keep patients engaged and mentally stimulated in daily life
- Promote policies that improve health outcomes
The Health System
The overall health system includes all the organizations involved in providing healthcare to a patient with chronic health conditions, including hospital or doctor’s office visits, physical therapy, and in-home nursing care. These organizations can:
- Work to consistently improve systems with patient quality of life as a top priority
- Give financial incentives to providers based on the quality of care they provide
- Facilitate coordination between the multiple care providers needed for the treatment of chronic illnesses
Self-Management Support
Even with good community and health system support, a patient managing chronic illness needs the tools to be able to access this support. Patients that are empowered to understand and direct their care will have better outcomes as they are able to manage their own health more effectively. Some of the tools needed to prepare patients for this self-management include:
- Encouragement to create goals and make a plan for managing their health between healthcare visits
- Physical tools and training on how to use them for self health monitoring, like blood pressure cuffs or blood sugar testing equipment
- Access to information on what community and health services are available and how to access them. This could include things like phone numbers for nurse check-ins, dates and times for support groups, and information about how to schedule transportation assistance for medical appointments.
Delivery System Design
Patients with multiple chronic conditions often struggle to keep track of all their needed healthcare appointments, medications, care providers, and lifestyle recommendations. The delivery system needs to help patients manage these complex elements so patients are able to get the full benefit from their care. A CCM platform, like TimeDoc, that automates care planning can help care providers implement a delivery system that serves patients best.
Decision Support
Healthcare staff need to be kept up-to-date on current evidence-based best practices for chronic condition management. This means the healthcare system needs to provide ongoing training and give clinicians enough time and resources to carry them out. This way patients are provided with the best information available and educated appropriately on how to best manage their illnesses.
Clinical Information Systems
Helping patients manage chronic medical conditions takes medical staff, resources, and time to do well. There is a lot of information to keep track of; everything from patient medical histories, to new knowledge on the best treatments for diseases. Organizing all this data so it’s easily accessible is the role of clinical information systems. These systems also need to:
- Remind healthcare staff, care coordinators, and patients of recommended appointments and check ins to be scheduled
- Identify patients in need of chronic care management or preventative care to facilitate proactive treatment
- Review staff and facility performance to improve care and support
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.
TimeDoc Health: Highlighting the Importance of Chronic Care Management
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.