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The Most Common Chronic Diseases and How to Manage Them With CCM

Jon-Michial Carter
Written by Jon-Michial Carter

Chronic disease is the leading driver of death, disability, and illness in the United States of America. According to the Centers for Disease Control (CDC), over 70% of all deaths in the United States are caused by one or more chronic diseases. Heart disease alone is responsible for one in four deaths in America each year. Even when they do not result in fatalities, poorly managed chronic diseases severely worsen an individual’s quality of life. Chronic disease can limit patients’ mobility, their ability to work, and their capability to care for themselves independently and can exacerbate their mental health conditions.  

Chronic diseases also place a significant economic strain on both the American healthcare system and the workforce. As of 2022, the annual United States health expenditure totaled a staggering 4.5 trillion dollars. 90% of these expenditures were directly correlated with chronic and mental health conditions. When you factor in the economic costs of chronic diseases, like lost productivity, the costs are even greater. The Harvard Business Review estimates that chronic illness costs the American workforce anywhere from $150-250 billion annually. Diabetes alone totals $413 billion in combined healthcare costs and lost productivity. 

Despite its economic advantages, the United States' ability to manage chronic diseases ranks poorly compared to other developed nations. A paradigm shift in how we approach healthcare is required to preserve the health of our aging population and ensure optimal clinical outcomes and quality of life for patients across this country. Chronic Care Management (CCM) is a program introduced by the Centers for Medicare and Medicaid (CMS) designed to improve the quality of care administered to chronically ill patients. In this article, we will explore the prevalence of chronic diseases, the challenges in managing them effectively, and how implementing a CCM program can elevate your practice’s chronic disease care management.  

What defines a chronic disease? 

A chronic disease is an illness that lasts for a year or longer. Chronic diseases tend to exacerbate with time, limit daily activities, and place patients at risk of functional decline, and in severe cases, disability and death. Chronic diseases often require ongoing medical treatment, monitoring, and medication to manage them. While they frequently cannot be cured, many chronic diseases can be controlled with proper medical intervention and lifestyle alteration.

The definition of chronic disease is broad and encompasses various illnesses and conditions. Some chronic diseases indicate an immediate deterioration of quality of life, like Alzheimer’s Disease. Other chronic diseases, like hypertension, can be managed by incorporating targeted behavioral changes like improved diet and exercise into a patient’s lifestyle. Chronic mental health conditions, like depression, can also cause significant health problems if left untreated.

What are examples of chronic diseases? 

Some of the most prevalent chronic diseases are:

  • ALS (Lou Gehrig’s Disease)
  • Alzheimer's Disease and Dementia
  • Arthritis
  • Asthma
  • Cancers (most commonly including lung cancer and colorectal cancer)
  • Cardiovascular Disease
  • Chronic Kidney Disease
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Crohn’s Disease (and other inflammatory bowel diseases like Irritable Bowel Syndrome and Ulcerative Colitis) 
  • Cystic Fibrosis
  • Depression
  • Epilepsy
  • Hypertension
  • Obesity
  • Oral Health
  • Osteoporosis
  • Parkinson’s Disease
  • Reflex Sympathetic Dystrophy (RSD) Syndrome
  • Stroke
  • Type 2 Diabetes 

What are the most prevalent chronic diseases in the United States of America?

Cancer, diabetes, and cardiovascular disease are the leading causes of death in the United States. All three of these conditions are categorized as chronic diseases. In fact, over two-thirds of all deaths in the U.S. are caused by only five chronic diseases: cardiovascular disease, diabetes, cancer, stroke, and chronic obstructive pulmonary disease (COPD).

What causes the prevalence of chronic diseases?

Some chronic diseases are caused by a patient’s lifestyle and behavioral patterns, while others are genetic. Some chronic illnesses can also be caused by environmental factors, like prolonged exposure to toxins, chemicals, or air pollution. Smoking and tobacco use, physical inactivity, excessive alcohol consumption, and poor diet and nutrition are all common risk factors that contribute to the rise of chronic diseases in the United States. 

Many chronic diseases can be avoided or even reversed by timely clinical interventions that identify these risk factors and provide patients with individually tailored wellness plans. Chronic illnesses that are not directly caused by the patient’s risk factors also benefit from early interventions. For example, stage 4 colorectal cancer is three times more expensive to treat than stage 1 colorectal cancer. 

However, chronic illnesses often have complex causes that demand a more nuanced understanding of the interplay between health and social factors. Social Determinants of Health (SDOHs) are non-medical risk factors contributing to chronic disease development. For example, patients unable to access preventive health services because of a lack of health insurance may not catch a chronic disease early enough to allow for effective interventions. Patients living in food deserts do not have access to nutritious meals and are more at risk of obesity, which can provoke many chronic illnesses. Patients in rural communities may not have easily accessible clinics or hospitals and not receive life-saving cancer screenings or medical attention. 

Learn more: Top 10 Chronic Disease Risk Factors

What are the most common chronic diseases in older adults?

Over 79% of American adults over the age of 70 have at least one of these seven chronic diseases: 

  • Arthritis
  • Cancer
  • Diabetes
  • Heart disease
  • Hypertension
  • Respiratory disease
  • Stroke

As the population ages, their risk of chronic disease development and exacerbation increases. This vulnerability is particularly pronounced in older adults. According to research by the National Council on Aging (NCOA), 94.9% of adults over the age of 60 have at least one chronic condition. 78.7% of them have two or more simultaneous chronic diseases. CDC research found that Medicare beneficiaries with two or more chronic conditions were responsible for 93% of Medicare’s expenditures yearly. 

These patients are more likely to live on fixed incomes and face economic precarity and social isolation, making them even more at risk of expedited decline from these diseases. Medicare-backed programs, like Chronic Care Management (CCM), were introduced specifically to target this vulnerable population and aid them in their management of chronic disease. Programs like CCM provide Medicare beneficiaries meaningful early interventions and life-saving preventative care. 

The challenges of managing chronic diseases

Chronic diseases present a unique set of challenges to healthcare professionals. Every patient has a unique familial history, set of risk factors, and combinations of health conditions that make the administration of care complex. Chronic disease requires a significant investment of time and energy into personalized healthcare plans from both healthcare professionals and patients alike. Patients may be reluctant to alter their lifestyles or try medications. If they aren’t properly educated on their conditions or are fatigued with navigating a complex and poorly coordinated medical system, engaging them is even more difficult. Diverse chronic conditions often present in unison, which can further complicate treatment plans.  

1. Educating and engaging patients

The success of chronic disease treatment is inextricably tied to patient self-management. For example, a diabetic patient who does not improve their diet or increase their physical activity will face a much more difficult path that could result in immobility, blindness, and other serious health complications. However, empowering patients to take charge of their health can be challenging. Patients may struggle to understand the importance of adhering to their treatment plans if they’re not provided with engaging, accessible healthcare information. Healthcare professionals must invest in ongoing patient education, as helping them understand their conditions, risk factors, and medications can lead them to optimal clinical outcomes.

Chronic illnesses are also an ongoing commitment. Patients must continue to monitor their progress, adhere to medications, and attend the necessary screenings and labs their diseases require. This can be exhausting, and patients who are not actively engaged in their care journey may abandon their wellness plans altogether. Patients suffering from mental health conditions like depression or social isolation and loneliness are also at particular risk of disengagement. Patient activation can be difficult for practices to maintain, especially if they only see a patient a few times a year.  

2. Managing multiple chronic diseases simultaneously

Chronic illnesses frequently manifest together. For example, many patients diagnosed with diabetes also have high blood pressure and high cholesterol. If these conditions are poorly managed, they can exacerbate one another and result in life-threatening cardiac events like coronary heart disease and congestive heart failure. 

Chronic diseases can also present in unison despite unrelated causes. A patient diagnosed with cancer may also develop mental health illnesses, like depression. If they slip into depressive episodes, they may decide to forgo surgical interventions, discontinue treatment plans, and socially withdraw. This could lead to the exacerbation of both their cancer and their depression.

Learn more: The Challenges of Managing Multiple Chronic Conditions

3. Allocating limited healthcare resources 

Many healthcare practices are overburdened with heavy workloads and staffing shortages and may struggle to obtain the necessary resources to effectively administer care. Chronic disease management demands a hefty investment of time and energy to be effective. However, many physicians already face intense pressure to keep patient wait times low while still delivering comprehensive care. Many clinical staff members are tasked with keeping track of CPT billing codes for Medicare, refilling medication, scheduling appointments, and processing insurance claims.  

Amidst all this, many practices may find it overwhelming to implement new preventive care and care planning services for their chronically ill patients. Starting an in-house program like Chronic Care Management is even more difficult for these overworked practices. 

Learn more: 11 Features of the Best Chronic Care Management Companies

Addressing chronic diseases with Chronic Care Management

Chronic Care Management (CCM) was launched by CMS in 2015 to improve the quality of care delivered to patients with chronic diseases. CCM empowers chronically ill patients by providing care coordination services, preventive care resources, and ongoing education to actively engage them in their healthcare journey. CCM also reduces healthcare costs and resource usage while compensating healthcare providers for their investment in the program. CCM programs provide patients with physician-designed comprehensive wellness plans that target their conditions and place them in optimal positions for favorable clinical outcomes. The program is available to all consenting Medicare Part B beneficiaries with two or more chronic diseases.

However, implementing CCM programs in-house demands a daunting amount of additional work for healthcare professionals. Effective CCM implementation requires a sophisticated telephonic infrastructure, rigorous documentation, and additional staff dedicated to enrolling patients in the program, managing patient churn, and providing beneficiaries with monthly check-ins from clinical staff. Many practices find themselves unable to maintain the program using internal resources alone, and often abandon the enterprise altogether without assistance.   

Learn more: What Conditions Qualify for Chronic Care Management? 

Elevate your chronic disease care with ChartSpan’s CCM service

ChartSpan is an industry-leading provider of turnkey Chronic Care Management services. ChartSpan equips your practice with everything you need to successfully launch a CCM program and transform the care provided to your patients battling chronic diseases. With ChartSpan, practices do not need to take on the additional pressures of starting a CCM program from scratch. 

We take ownership of the patient education and enrollment process, manage patient churn, and provide patients with the required services to qualify your practice for maximum CMS reimbursements*, under the provider’s supervision and with your practice’s approval. Through our proprietary RapidBill technology, we handle almost the entire billing process, allowing your practice to receive a recurring stream of revenue* simply by approving and submitting a monthly invoice to CMS. In addition to monthly calls with our care managers, your enrolled patients will have access to clinical advice every hour of every day of the year via our 24/7/365 nurse care line.

*Results may vary by provider. 

Provide patients with monthly communication between clinical visits

Every enrolled patient will receive a minimum of 20 minutes of services from a dedicated care manager each month. Care managers can use this time to assist patients with self-management tips, review care plan progress, and address any obstacles a patient encounters with medications, treatments, or symptoms. Care managers can also identify worrying new or worsening symptoms or risk factors and help coordinate timely interventions to prevent the exacerbation or development of illnesses. If a patient doesn’t answer the phone, their care coordinator will still perform activities like crafting care goals and plans or reaching out to them with educational materials. 

While your practice may only see a patient once or twice annually, our care managers ensure that these patients remain engaged in their healthcare journey throughout the year. This consistent cadence of communication and ongoing commitment to wellness is vital for patients managing multiple chronic diseases. 

Help close gaps in care by providing care coordination, medication refills, and SDOH assistance

Mental health, demographic and environmental factors, and socioeconomic challenges all contribute to chronic disease development. However, through consistent communication, ChartSpan’s care managers can help patients overcome these obstacles on their journey toward optimal health. Care managers can arrange transportation to and from appointments for patients, ensuring they do not miss preventive screenings and vaccinations. They can also assist patients with medication refills and deliveries, encouraging ongoing medication adherence

If patients are facing economic hardships or housing instability, our team can help them find assistance to mitigate these strains. Care managers can connect patients to local resources like food banks, community centers, and financial support programs. These measures help close gaps in care and facilitate preventive engagement in healthcare. The human connection also adds an element of empathy to the healthcare navigation process, strengthening the trust and loyalty between your practice and your patients.

Care coordination is also often challenging for patients with chronic diseases. These patients frequently see multiple healthcare providers across disparate networks. These providers might schedule follow-up appointments and screenings, prescribe medications, and order lab work. ChartSpans’ care managers help enrolled patients access test results and ensure they can smoothly and seamlessly navigate their complex care journey, as well as notifying their CCM provider of the care they’ve received from other providers. 

Work on care plans and care goals tailored to specific chronic conditions 

Our care managers possess a wealth of information and resources on the many prevalent chronic diseases that plague older Americans. In addition to adhering to the physician-created wellness plan, we can assist patients in creating patient-led care plans and care goals that alleviate their symptoms and improve their ability to self-manage their conditions. 

Contact us and learn more about how we can help your practice transform chronic disease care. 

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