Why Care Coordination is Key to Improving Chronic Illness

Care Coordination

In previous blogs, we have discussed programs whose goals are to improve patient outcomes through quality care while increasing provider efficiency. An additional program provided by CMS to help in these efforts is the Chronic Care Management (CCM) program. CMS has made CCM available to Medicaid ACOs as they seek to create savings for both patient and provider while simultaneously coordinating care for the large chronically ill population.

Care Coordination For Chronic Illness

The chronically ill population accounts for 84% of all healthcare spending. An estimated 117 million adults having one or more chronic health conditions, and in 2014 seven of the top ten causes of death were from chronic diseases. With such a large population of chronically ill, the need for improved care is one we can all recognize. CMS has provided CCM as an incentive in these efforts to provide patients with dedicated teams managing their health, comprehensive plans of treatment, and ongoing support in between visits. Provider benefits include care coordination improvement, patient compliance and connection, and growth of their practice or ACO.

At the heart of these efforts is creating and promoting wellness for Medicaid recipients by looking at the continuum of care beyond only those provided by individual providers or ACOs. Chronic Care Management (CCM) is a patient centered program targeting those who suffer from two or more chronic illnesses that require a coordination of care from different providers. Coordinating care takes time and costs money, and the CCM program provided by CMS offers providers the opportunity to be reimbursed for costs associated with coordinated care. Medicaid providers can benefit from CCM, whose objectives harmonize with those of community care coordination programs.

Improving Chronic Care Management

In California, one ACO uses care coordinators to help patients manage their chronic diseases by learning about their care goals, managing their appointments, assisting with transportation, ensuring they have medications and proper instructions for their use, and help them discover additional community resources that can help them. This requires time, communication, and interaction.

The coordinator of these efforts in Ridgecrest, California, Celia M. Mills, said sometimes patients are deemed non-compliant with the guidelines when in reality they are simply unable to find transportation to their appointments. By adopting CCM, they have seen these difficulties alleviated in their chronically ill population.

For ACOs who wish to offer CCM to their patients, they must obtain permission from the patient and provide a thorough explanation of their CCM services. ACOs can offer CCM to members of the eligible population, as defined by patients with multiple (two or more) chronic conditions that are expected to last either 12 months or until the patient’s death. Chronic conditions can include Alzheimer’s, arthritis, asthma, cancer, Chronic Kidney Disease (CKD), depression, diabetes, and hypertension, amongst many others. Medicare-Medicaid dual-eligible patients also have access to CCM; it is estimated approximately 11.4 million are dually eligible. Each state has varying requirements for dual-eligible patients, so be sure to check their guidelines.

Billing practitioners eligible for reimbursement include physicians, certified nurse midwifes, clinical nurse specialists, nurse practitioner, physician assistants, and other specialists. CMS has established guidelines determining what can be billed and how, and one of the primary factors preventing more providers from using CCM is the paperwork and reporting requirements. Recognizing this, CMS has simplified and reduced billing and documentation rules, especially around patient consent and use of electronic technology.

The Connected Care Campaign

Their efforts to improve the program aren’t limited to only providers. Through the Connected Care campaign, the CMS Office of Minority Health and the Federal Office of Rural Health Policy at the Health Resources & Services Administration is raising awareness of the benefits of CCM for patients with multiple chronic conditions and providing healthcare professionals with resources to implement CCM.

As patients learn about the benefits of CCM, they will develop a comprehensive care plan that includes a list of problems and assessments, expected outcomes and prognosis, measurable treatment goals, symptom and medication management, planned interventions and identification of individuals responsible for each intervention, available community and social services, and agency specialists who will coordinate the efforts of the various providers.

Patients seeking information on CCM are told they will receive personalized assistance from a dedicated healthcare professional who will work with them to create a care plan that coordinates services among different organizations and enables timely access to expert assistance in meeting their healthcare goals. These benefits should be worth the effort of most Medicaid ACOs to provide, despite the time required for compliance. Through improving the care for the chronically ill, providers will likewise experience an increase in patient satisfaction. These are certainly goals worthy of our efforts.

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