Chronic Care Management

CMS recognizes care management as one of the critical components of primary care that contributes to better health and care for individuals, as well as reduced spending.

The CCM service is extensive, including structured recording of patient health information, maintaining a comprehensive electronic care plan, managing transitions of care and other care management services, and coordinating and sharing patient health information timely within and outside the practice.

CMS recognizes chronic care management as one of the critical components of primary care that contributes to better health and care for individuals, as well as reduced spending.

With CCM, an electronic care plan based on the individual’s physical, mental, psychosocial and functional status is developed. This individualized care plan focuses on each patient’s chronic diseases with a goal of optimal evidence based medical management.

CCM providers share the electronic care plan with facility caregivers, as well as to the patient’s outside providers, ensuring continuity of care. A copy of the care plan is also provided to the patient and/or caregiver. CCM provides an additional goal driven focus on the patient’s chronic diseases while maintaining the same 24-hour-a-day, 7 day-a-week access to healthcare providers that the patient and family are accustomed to.

Therapeutic Taking Care Of Her Client In Hospital Room

What is Chronic Care Management?

Chronic Care Management (CCM) is the active coordination of care and services completed outside of regular patient visits on patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. CCM services are typically non-face-to-face and ensure a higher level of care coordination.

How would I benefit from Chronic Care Management?

Medicare (CMS) recognizes CCM as one of the critical components of primary care that contributes to better health and care for individuals, as well as reduced overall healthcare spending. CCM enhances patient’s access to qualified health care professionals and clinical staff working on their behalf.

How is this different from a normal Doctor/Nurse Practioner visit?

Chronic Care Management (CCM) service is more extensive than what is typically involved in a doctor or NP visit. CCM includes structured recording of patient health information, maintaining a comprehensive electronic care plan month to month, managing transitions of care and other care management services, and coordinating and sharing patient health information timely within and outside the facility and practice. A person-centered, electronic care plan is maintained, based on physical, mental, cognitive, psychosocial, functional, and environmental (re)assessments, and taps into an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed).

Is there a charge to the patient for this service?

For patients who are both Medicare and Medicaid eligible, there is no copay or fee for which patients are responsible.

How is this different or is this in addition to what the Nursing Facility does for me?

CCM utilizes nursing facility care plans, nursing and therapy notes, and other nursing facility documentation and insight (such as that from Nurse Aides and Dietary Personnel) to fully assess and guide Provider-level care plans intended to enhance the overall care management of the patient. The goals of the nursing facility care plan and CCM are very consistent – to maintain the well-being and stability of the patient, and to manage the patient’s medical conditions as closely as possible.

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