Chronic Care Management

Today, approximately one in four adult Americans has multiple chronic conditions. Of those adults aged 65 and older, 68.4 percent have multiple chronic conditions that require daily management.

In 2010, among the 14 percent of Medicare beneficiaries with six or more chronic conditions, more than 60 percent were hospitalized at least once, accounting for 55 percent of total Medicare spending on hospitalizations. Further, beneficiaries with six or more chronic conditions also had hospital readmission rates that were 30 percent higher than the national average.

This is the most significant statistic for CMS: In 2014, the estimated total annual cost of readmissions for Medicare was $26 billion, with $17 billion of that considered avoidable costs.

As these numbers indicate, there is a clear incentive for providers who effectively use technology and proven interventions to help keep these patients in their homes. Reimbursements are increasingly starting to reflect this trend.

Managing Chronic Conditions

Enter Medicare’s Chronic Care Management program (CCM), a telehealth-enabled initiative created by CMS on January 1, 2015, to help better treat patients with multiple chronic conditions. Through monthly 20-minute care coordination sessions, CCM ultimately aims to reduce preventable readmissions, emergency room visits, nursing home intakes and other utilization costs that often don’t have much of a positive effect on the patient’s long-term health. Better ongoing assessments can be made and acted upon when a patient is more engaged with a clinical expert.

With CCM, check-in sessions are delivered by a certified medical professional on behalf of the primary care practice, with the ultimate goal of helping patients understand their plan of care while keeping the provider informed of any change in clinical status.

Once a clinical encounter is completed, the medical professional updates the electronic health record (EHR) with the recorded information. Depending on the individual, providers offering CCM can fulfill a wide spectrum of needs, but it really boils down to the following: “How can I best serve the patient, and ensure he or she is receiving the resources necessary to handle personal care?”

Engaging Patients

At their most basic, CCM and related programs rely on the concept of patient engagement, a buzzword born out of health care’s shift toward value-based care. Simply put, patient engagement means that the patient is a vital and important contributor to his or her health care goals. Patient engagement can describe a variety of services in the telehealth and CCM world, but the gist of the concept is information—specifically, the patient is a provider of personal health data, which allows all those involved in the care delivery chain to make accurate and informed decisions about how to best provide care.

With CCM, this can include information provided verbally by the patient, clinical conclusions drawn from the attending medical professional and even data provided by a bedside monitor. This data collection is especially crucial for patients with co-morbid conditions, as waiting weeks or even months between in-person check-ins is far too large of a timeframe to accurately and safely manage these complex symptoms.

Looking past the bells and whistles of telehealth, there is no overstating the worth of having a dedicated, informed expert handling these cases. Often, CCM patients are managed by a registered nurse who oversees their care plan creation and management. Under the RN, the patients are continuously monitored and matched with the best CCM resources suited for their needs. This may include health coaching, clinical expertise or even social service resources.

Taking Care to the Next Level

Beyond the use of telehealth to update the EHR, the true value of CCM is the way the program is designed to help optimize patient care outside the four walls of the primary care office. A particularly interesting factor of CCM is the ability of the medical professional to review the patient’s medical chart and then immediately employ this clinical information to inform treatment decisions and extended care coordination.

Medication adherence is one area of care where this is most evident. As we all know, patients with chronic conditions must purchase and juggle multiple prescriptions, and often have a hard time with two factors: 1. cost and 2. adherence to specific medication routines. Concerning the cost issue, CCM professionals who identify that a patient is having trouble with high medication prices can actually use the patient’s geographic location to suggest another pharmacy—perhaps where the drug is cheaper. Further, professionals can also review the patient’s chart to see if the patient might be eligible for discount programs or coupons that make these costs more manageable.

The second point—medication adherence—is particularly relevant as many CCM patients manage a variety of pills to deal with hypertension, diabetes, high blood pressure, etc. These must be taken in a specific order and at certain points throughout the day. If a patient is confused about his or her medication routine, a quick phone call to the CCM professional is all that is needed to clarify the matter. It is easy to see how a patient could go off their medication routine without collaboration and assistance, as many non-CCM patients do when they have to wait for an appointment with their primary care physician. This is often the fastest path to the nearest emergency department.

This point is directly correlated to the theme of proactively reducing readmissions, as polypharmacy—mixing medications—is a common practice, but one that can put patients in danger of adverse effects. If a patient is discharged from the hospital and given a new pill for acute hip pain, this drug could potentially upset the delicate balance of his established medication routine. With CCM, the medical professional can spot this possible issue and adjust the routine accordingly.

The use of these touch points extends to maintenance of medical technology as well. For example, a patient could inform his or her doctor that their electronic wheelchair is defective, or that their medical bracelet has been malfunctioning—both of these might be considered low priority needs by the patient and would never be discovered unless the patient called or there was an in-person visit. However, as those who specialize in the care of older adults and individuals with chronic conditions know, even seemingly insignificant factors can quickly affect care and a healthy clinical status.

Looking Forward

What’s next? If we remember those earlier stats about the costs of patients with chronic conditions, it is evident there is a quickly developing market for providers who go above and beyond to better manage and understand the needs of their valued patients. As programs such as CCM become more widely integrated into private practice, hospitals and health systems—in addition to the evolution of medical devices—it can be reasonably assumed that Medicare will respond appropriately and fully cover the use of technologies that facilitate this need.

If so, we will start to see programs such as CCM increasingly incorporate remote monitoring and patient engagement technology such as smart watches, home health devices and even Hello Health’s Wellbox Platform into everyday care and reimbursements—all with the tacit goal of providing real-time health information that allows for timely, clinical interventions. We are no longer in the dark ages of health care in terms of health IT, and it is now easy to envision a future where physicians are able to review a chart with minute-to-minute health data related to insulin levels, cholesterol increases or even the degree of hip mobility in a recent total joint replacement patient.

The technology is here to stay, and savvy providers will see not just a venue for increased reimbursements, but rather an opportunity to greatly improve the lives of older patients and keep them out of inpatient facilities. We are increasingly gaining insight into the factors behind readmissions and poor health outcomes, and it is now clear that data collection and patient engagement is the key to the future of a successful health care system.

To paraphrase my favorite 1970s television show, “We have the technology.” Now is the time to use it.