Chronic Care Management Care Plans Matter

With the start of a new year comes new goals, intentions, and aspirations. Did you know that the majority of the most popular new year resolutions have to do with improving health in one way or another? They also can be some of the most challenging. Setting, working towards, and achieving health goals can be intimidating and overwhelming at first. But with a well thought out plan and someone to guide you along the way, you can easily get on track to better health. 

One group who may have an especially hard time achieving health goals on their own is elderly patients with multiple chronic conditions. Since patients in this category often struggle with cognitive/memory loss and depression, they do not always have the mental or emotional drive to adhere to a strict health plan. Many need consistent check-ins and encouragement to continue towards a goal. Thankfully, Medicare’s preventive program, Chronic Care Management (CCM), offers a solution for Medicare beneficiaries: the Chronic Care Management care plan.

What is a Chronic Care Management care plan? 

In 2015, the Centers for Medicare and Medicaid Services began offering reimbursement to healthcare providers for providing a preventive program called Chronic Care Management (CCM). This program, billed with CPT code 99490, is intended to help Medicare patients with multiple chronic conditions stay on top of their health so that they do not experience additional functional decline and can avoid visits to the emergency department or hospitalizations. 

One of the compliant requirements of Medicare’s Chronic Care Management program is that every patient must have a care plan and have access to that care plan. This all-encompassing care plan is a comprehensive document required to be shared with the patient’s network of providers so that they can all be aware of any changes in the patient’s healthcare status. The care plan is stored in the provider’s electronic health record (EHR) and updated regularly.

What does the CCM care plan include? 

The comprehensive CCM care plan includes documentation of everything a healthcare provider would need to know about a patient’s health. This includes medical history, condition list, requested medical records, medications, allergies, and a list of providers. It also includes documentation of every interaction completed by CCM personnel, under general supervision; such as planning, goals, and patient updates. 

During monthly outreach, the clinicians who are part of the CCM care team will work with each patient to develop a unique care plan that is specific to the patient’s chronic conditions. For example, a patient with diabetes may have a custom plan built to improve their blood sugar monitoring and to start meal planning. This may include starting a daily journal to record monitoring and to participate in cardiovascular activity a certain amount of times each week. The CCM clinicians will work on implementing specific, measurable, achievable, relevant, and time-specific (SMART) goals for the patient so they are easier to track and achieve. Every calendar month when the clinician and patient connect, they will check in on progress and make any necessary adjustments. This is all recorded in the comprehensive care plan and shared with the patient’s provider. 

Why is a CCM care plan important? 

The comprehensive CCM care plan is crucial to closing gaps in care, especially when there are multiple conditions and providers involved in a patient’s care. All health care professionals involved in a patient’s network should be made aware of new changes in the patient’s health information, whether that is a primary care provider, specialist, or the CCM team providing care coordination services. The care plan can act as the center of this information workflow.

In addition, the condition-specific care plans and goals included in the CCM care plan document play a pivotal role in improving patient outcomes. Setting realistic goals through Chronic Care Management services helps the patient with self-management of their chronic conditions, while still providing a guiding hand along the way. Without this guidance and preventive care, patients are highly likely to stray away from healthy habits and in turn, worsen their overall health. 

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