Chronic Care Management: The Missing Piece In Coordinated Care?

The healthcare industry is in constant transition in attempts to provide better integrated patient care. Patients with multiple chronic conditions are one of the largest groups whom are deeply impacted by the lack of communication among providers. The absence of coordinated care for these patients has resulted in several unwanted consequences, such as a high increase in hospital readmission and re-visits. However, the large proportion of these admissions and revisits can be avoided through managed chronic care.

Many of these rapidly evolved healthcare policies have managed to bring enormous accomplishments in terms of improving quality care and reducing cost consumption. One of the programs introduced solely to cater coordinated care for patients was the Chronic Care Management Program (CCM). Studies have shown that prior and proactive chronic care management can help not only reduce hospital visits but also helps preventing readmission by engaging practices to arrange clinical/non clinical resources for patients with acute symptoms.

This program has been specifically designed to address the needs of patients with two or more chronic conditions by improving care coordination, manage ongoing medical conditions, and avoiding future hospitalization costs. The results of chronic care interventions have surpassed all expectations and have played a huge factor in cutting down readmission’s cost.

CCM will continue to play its fundamental role, as the number of Medicare beneficiaries is expected to increase by 2030. In the United States, an estimated one in five elderly adults returns to the hospital within 30 days of being discharged. CCM aims to assist in significantly reducing this statistic. In 2013, the average cost of readmission for those aged 65 and older was $13,800. The total annual costs for hospital readmission in 2011 was $41.3 billion, with Medicare costs alone totaling $24 billion. Cases that could likely have been avoided with proper care cost an estimated $17 billion annually.

With the stress being placed on proper and proactive chronic care management, providers have also been incentivized to engage in models that improve coordinated care. Although there was a lot of hesitation when CCM was first introduced, many providers are now seeing the positive impact after implementing it. Not only were patients satisfied, many were able to avoid complications that would have likely resulted in hospitalization or in some cases, re-hospitalization.

The CCM program also allows providers to bill for and obtain reimbursement for helping patients manage their health conditions between office visits.  Practices now have the opportunity to receive reimbursement for these services, many of which were already being performed without compensation. The coordination between office visits for patients with multiple chronic conditions has often been inadequate. The lack of integrated care can often leave patients feeling frustrated and hopeless.

An increasing level of care providers sometimes experience burnout due to lack of adequate resources. The Chronic Care Management Program is a great way for providers to add additional revenue to their bottom line without the extra work. Many have attempted to perform Chronic Care Management in-house but were unable to do so successfully due to their lack of resources.

Passionate Care Management is the perfect solution for any practice. We work as an extension of your office in order to increase patient engagement and monitor in-between office visits. Outsourcing CCM allows the practice staff to focus on their daily tasks without adding extra work. Our team consists of highly trained and certified individuals, who focus solely on patient care. They work closely with every patient in order to develop monthly care plans with goal-settings in accordance with their physician’s expectations. Our proven track of providing the right program management team along with our software solution will give practitioners the confidence that their patients are well cared for.

The Centers for Medicare & Medicaid Services (CMS) identifies Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. Take advantage today!