Chronic Care Management

March 11 2024

Imagine elevating the quality of health care for your patients while streamlining your post discharge care process. Chronic care management (CCM) programs aim to achieve this and more. You can ensure patients with multiple chronic conditions get excellent care while your health center receives the benefit of increased care coordination and additional staffing support. 

While chronic care management programs have rigorous requirements that have the potential to increase your workload and slow productivity, Medrina offers a workable solution. Our skilled team of providers and chronic care coordinators can assist you with a streamlined workflow and care management procedures. When your care center starts offering chronic care management, everyone benefits. 

What Is Chronic Care Management?

Chronic care management is a program that ensures continuity for healthcare providers overseeing the needs of patients with two or more chronic conditions. The primary objective of CCM is to enhance patients' well-being, help them manage their symptoms, prevent complications and empower patients through self-management tools. Patients who qualify can receive assistance outside a hospital or skilled nursing facility. 

The CCM program offers a range of services, including:

  • Personalized care plans
  • 24/7 access to health care professionals
  • Support for prescriptions and appointments
  • Coordination with specialists
  • Assistance during transitions between health care facilities
  • Patient education 

By providing a structured and coordinated approach, these programs enhance the patient experience and reduce hospital readmissions for fewer emergency room visits and improved management of chronic diseases. 


The Purpose of Chronic Care Management

Without consistent and coordinated treatment, a patient's health can rapidly decline, resulting in visits to the emergency room and hospital readmissions. In addition, the patient’s Social Determinants of Health can further complicate or introduce additional barriers into their recovery process. These occurrences lead to higher expenses for both the patient and health care provider. 

Some of the goals of CCM include: 

  • Coordinating patients' care: Effective coordination between primary care providers, specialists and care coordinators can help improve and manage a patient's condition.
  • Preventing complications: CCM is a monthly program focusing on preventative measures to manage chronic conditions and reduce the risk of exacerbations and other health issues between visits. 
  • Improving patient outcomes: By preventing or avoiding unnecessary gaps in care, patients can recover quickly and efficiently in the safety of their own homes. 


Qualifying Conditions

To be eligible for CCM, patients must meet specific criteria such as having two or more chronic conditions expected to last at least 12 months or until the patient's passing. Patients can also qualify when they have two or more conditions that could potentially lead to death, decompensation or acute exacerbation, or functional decline. 

Examples of chronic conditions include but aren’t limited to:

  • Diabetes
  • Asthma
  • Atrial fibrillation
  • Hypertension
  • Autism spectrum disorders
  • Cancer
  • Arthritis (osteoarthritis and rheumatoid)
  • Cardiovascular disease
  • Depression
  • Chronic obstructive pulmonary disease (COPD)
  • Infectious diseases like HIV and AIDS


Benefits of Chronic Care Management Programs

Chronic care management services hold a host of benefits for recipients and providers. Explore some of them below:

  • Personalized and readily available care: CCM offers a systematic and customized method to effectively manage chronic diseases by monitoring symptoms, addressing potential issues and reducing the severity and frequency of acute episodes. Recipients have 24/7 telephonic access to health care — patients can get help for emergencies and therefore reduce health risks. Patients enrolled in a CCM program have seen significant improvement in managing their chronic conditions, reducing hospital admissions and emergency room visits. 
  • Greater care coordination: CCM promotes effective and comprehensive patient care by facilitating consistent communication and alignment among all caregivers, avoiding potential treatment overlaps and conflicts. 


How Can Medrina Help Your Organization?

CCM can improve patient care significantly, and both your center and patients can reap the rewards — but starting as a CCM provider can take some hard work. You'll often need to manually screen patients to find eligible candidates for the program, which can take up a lot of your time. Implementing the CCM requirements and changing your workflow to accommodate these stipulations will increase your workload. You'll also need the technical resources to coordinate each patient's care.

Because managing a CCM program can be challenging, you'll want to find a way to serve your care center and patients best while following the program. Partnering with an expert chronic care management provider can help you handle the intricacies of a chronic care management program.

Medrina's CCM program offers unique benefits:

  • Personalized service: When you partner with Medrina, we tailor our CCM plan to suit your care center. We are a physician-owned company and know the ins and outs of health care — we understand your and your patients' needs. Our physicians and care coordinators will uniquely engage with your team to find the most productive way to implement CCM procedures. 
  • Outsourced assistance: You can bring our qualified providers' expertise to your health care team and add knowledgeable care coordinators to handle CCM procedures smoothly. You and your team can focus on caring for your patients, and Medrina will handle your CCM needs.


Choose Medrina for Your CCM Needs

You and your patients can benefit from chronic care management services. Medrina is ready to help you coordinate your patients' health care needs so that you can focus on what you do best — caring for your patients. Contact our expert team to find out more about our services and how we can assist your care center. 

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