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The Chronic Care Model Explained

Jon-Michial Carter
Written by Jon-Michial Carter

Chronic Care Management (CCM) is central to many healthcare systems but is also expensive and time-consuming for providers. Chronic conditions are a leading cause of death in the US, and 84% of healthcare costs are devoted to treating them. 

Chronic Care Management can help with these issues. CCM embraces the framework of the Chronic Care Model to deliver quality care to patients with chronic conditions, using a preventative approach. Applying this model to your practice benefits you and your patients, but staffing, low patient enrollment, and high costs make executing CCM successfully challenging. 

Relying on a Chronic Care Management program frees your time to focus on in-patient care and supplies your practice with a stream of recurring revenue while providing patients with the ongoing support they need. We’ll explore the goals of the Chronic Care Model and how a CCM program like ChartSpan can help your practice meet those goals and improve outcomes for patients with chronic conditions. 

Who came up with the Chronic Care Model?

The Chronic Care Model was designed in 1996 and later revised in 1998 by Edward Wagner, MD, MPH. Wagner noticed individual providers rarely followed up on multiple chronic conditions, even though people with one chronic illness often have others. Wagner determined that physicians could manage chronic care more effectively and set out to create a system designed to manage chronic disease proactively. Wagner’s Chronic Care Model was further refined in 2003 by the Improving Chronic Illness Care (ICIC) program and became the framework we use today. 

The Centers for Medicare and Medicaid Services (CMS) realized the value of the Chronic Care Model and made it a part of their value-based care initiative, Chronic Care Management (CCM). CCM helps practices embrace the Chronic Care Model, mitigate chronic care’s financial challenges, and achieve better patient outcomes. Providers can also receive Medicare reimbursement when they offer Chronic Care Management to Medicare beneficiaries.

What is the Chronic Care Model?

The Chronic Care Model is a multifaceted framework for delivering quality care to patients with chronic disease. This roadmap applies to any provider and is moldable for many practice settings, populations, and chronic illnesses. The Chronic Care Model consists of six fundamental components:

  • Self-management support
  • Delivery system design
  • Decision support
  • Clinical information systems
  • Organization of health
  • Community

Each of the areas is adaptable to the organizational needs of the provider. The Chronic Care Model can be used to identify and manage the care of a group of patients with a specific chronic condition, such as diabetes, arthritis, or hypertension. The model also streamlines processes, like communication or scheduling. Ultimately, coordinating the care your patients receive and simplifying your practices’ operations creates a highly effective, outcome-based system.

6 Components of the Chronic Care Model 

CCM builds on the concept of the Chronic Care Model using six components to create a process personalized for each provider to care for their patients with chronic conditions.

1. Self-management support

Self-management focuses on helping patients take charge of their health. Educating patients about their chronic diseases and supporting them throughout their care empowers them and builds their confidence. Providers use evidence-based techniques to ensure patients with chronic conditions receive the necessary support to manage their conditions in their own homes. 

For example, if a diabetic patient doesn’t understand blood sugar fluctuations, they may not understand how their diet affects their condition. Robust education and resources might help them eat better and make significant clinical changes. Patients successfully managing their diabetes may reduce hospitalizations or emergency room visits. Minimizing medical requirements helps the patient save money and reduces the financial burden on the healthcare system as a whole.

2. Delivery system design

Clinicians and non-clinical staff must be clear on their role when participating in a Chronic Care Model-based CCM delivery system. Patients with chronic conditions need highly trained providers that are up-to-date on the patient’s condition.

Care for patients with chronic conditions requires a process or system that facilitates scheduling and follow-ups. Through a Chronic Care Model-based CCM delivery system, the provider can establish a way to schedule visits and receive regular updates on any change in condition.

3. Decision support

The Chronic Care Model framework helps providers make patient-centered decisions and encourages patient participation. Within this model, clinicians apply current, evidence-backed guidelines and patient preferences to their treatment for each chronic condition. Providers must also use the most recent patient information and account for changes in the patient’s condition when making decisions regarding the care of a patient. 

4. Clinical information systems

A clinical information system collects data for each patient with chronic conditions to help providers effectively monitor and care for those conditions. These systems are an essential aspect of the Chronic Care Model. Providers can communicate with patients and access their treatments, assessments, appointments, and care plans through a clinical information system. 

5. Organization of healthcare

The Chronic Care Model requires a proactive, quality-focused organization to care for chronically ill patients. Lead clinicians or nurses will champion improving chronic care management and preventative care. These leaders help patients create goals and provide relevant resources to other team members. 

6. Community

Partnering with community groups, like state or local agencies, non-profit organizations, or religious groups, helps healthcare systems fill gaps in care for chronically ill patients. Providers should also explain to patients that participation in community programs can improve their well-being and encourage them to get involved.

ChartSpan's Chronic Care Management program can assist your healthcare practice in implementing the Chronic Care Model. We collaborate with providers to establish patient goals and assist patients in managing their chronic conditions with regular check-ins and a 24/7 nurse call line. ChartSpan’s CCM system seamlessly integrates with your Electronic Health Record (EHR), providing physicians access to the most up-to-date patient information. In addition to these services, our software is designed to identify gaps in care, enabling targeted interventions to improve patient outcomes. 

Our commitment to patient well-being extends beyond medical care. We connect patients with valuable community resources, such as Silver Sneakers, local food pantries, meal delivery programs, and YMCA classes. By working closely with healthcare providers, ChartSpan facilitates connections within the community, ensuring that patients receive the resources that align with their specific needs.

Why is the Chronic Care Model important?

Six in ten adults in the U.S. have a chronic disease, and four in ten have two or more chronic diseases. Deploying CCM has been shown to improve outcomes in chronic conditions. Patients receive support and build self-confidence to become a participant in their care. They gain skills to care for themselves and their condition.

Caring for patients with chronic conditions consumes much of a provider's resources. Providers must keep records of appointments, test results, required follow-ups, visits to specialists and emergency departments, and any changes in the patient’s condition. In addition, providers must educate staff, stay abreast of the most recent studies, care for acute conditions along with existing chronic conditions, and do it all within a budget. 

The Chronic Care Model addresses the needs of the patient and the clinician in concert. Clinicians need a cost-effective program to help them manage the needs of patients with chronic conditions, and chronically ill patients need ongoing care and support. The needs of both parties can be met when the guidelines of the Chronic Care Model are followed and adjusted to fit into a provider’s organization. Patients receive management of their chronic condition, and clinicians receive administrative and clinical support to meet the needs of the patient cost-effectively.

With a Chronic Care Management program, healthcare providers have a system that supports the staff and helps them build stronger relationships with patients. Our CCM program encourages patients to be active, educated participants in their care with the aid of the ChartSpan team to support the patient and your practice.

Learn how we can help you manage patients with chronic conditions without sacrificing resources.

Chronic Care Management and the Chronic Care Model

The Chronic Care Model provides guidelines for effective Chronic Care Management (CCM), and CCM serves as a way to financially support providers as they aim to implement the Chronic Care Model. Providers can now receive monthly payments when delivering care coordination services to eligible Medicare beneficiaries. This change has helped many providers cost-effectively shift toward value-based care. 

Chronic Care Management requires the collaboration of providers and patients to manage a patient’s chronic care condition. It consists of monthly patient monitoring with follow-up visits and provider collaboration. In the past, chronic conditions were addressed only when a patient was seen in a provider’s office. This is no longer the case when CCM is in place. CCM aims to cost-effectively manage the health of patients with chronic conditions and reduce the number of patient visits.

With a CCM program, providers can receive monthly reimbursements when they provide care coordination services to Medicare-eligible beneficiaries. One study showed that Medicare and taxpayers can save over $30 per patient per month after reimbursement. Furthermore, a ChartSpan study revealed that our CCM providers saved over $601 per patient per month. It is cost-effective for providers to switch to CCM and value-based care. Providers can focus on improving public health while implementing a shared-savings strategy.

Learn how Chronic Care Management has evolved.

Is the Chronic Care Model Effective?

When providers implement CCM using the components of the Chronic Care Model, processes for managing chronic care and patient outcomes see long-lasting improvement. The efficacy of the Chronic Care Model and Chronic Care Management has been thoroughly studied and proven to improve patient outcomes. Patients receive better care and learn to self-manage their conditions through CCM. When practices address more domains of the Chronic Care Model, they perform better on chronic illness care processes and outcome measurements. 

Read our case study on relieving your practice workload with Chronic Care Management

How Chartspan Can Support Your Chronic Care Management Needs

Implementing CCM is not an easy feat. Many practices that struggle with CCM either lack the appropriate staff, don’t enroll enough patients to sustain the program, or fall short in cost-effective billing practices. Organizing the program can be overwhelming and your staff may become disengaged. Whatever the obstacles, ChartSpan helps providers overcome them and achieve the benefits of implementing CCM. Providers can focus on patient care while ChartSpan takes care of the rest.

Implementing CCM helps improve the health of your patients while managing costs. ChartSpan is the trusted solution for fully-managed CCM. We will take on the most challenging parts of CCM so you can continue providing top-notch patient care. Our experienced, attentive team is committed to helping you reach your goals. 

Reach out to us to learn more and receive a demo of how our Chronic Care Management program can help you implement the Chronic Care Model and improve patient care.

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