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Why Chronic Care Management care plans matter

Chronic Care Management (CCM) care plans can help Medicare recipients set, work toward, and achieve their health goals. All people can benefit from realistic nutrition, exercise, and social goals. But for older patients with multiple chronic conditions–like the patients who are eligible for CCM–setting and reaching these goals can be difficult. 

In addition to physical conditions, many adults over 65 struggle with loneliness and social isolation, which can lead to anxiety, depression, and memory loss. These mental health struggles make it especially hard for patients to achieve their health goals. Through Chronic Care Management, patients gain a care team who will check in with them every month. The team can help patients set goals and come up with strategies to achieve them. And all of these goals and strategies become part of 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, helps Medicare patients with multiple chronic conditions take charge of their health and reduce their risk of hospitalization and emergency room visits. 

The Chronic Care Management program requires that every patient have an accessible care plan. The care plan is a comprehensive document that includes a patient’s medical history and records of every CCM interaction the patient has.This document is shared with the patient’s network of providers so they can 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. At ChartSpan, patients can also access their care plan through the patient portal.

What does the CCM care plan include? 

The comprehensive CCM care plan includes a patient’s medical history and records, as well as lists of their medications, allergies, and providers. This information is pulled from the EHR. 

The care plan should also include documentation of every interaction completed by CCM personnel. 

When building a care plan, the CCM team might add: 

• A list of the medical conditions being addressed
• The patient’s prognosis and expected outcomes
• Notes on symptoms
• Details about medication management
• Relevant notes from other practices and specialists
• Quantifiable care goals
• Planned interventions to help patients reach those goals

Care Plan Goals and Strategies

Care goals and strategies to reach those goals are especially important parts of the care plan. For example, at ChartSpan, nurses partner with patients to create their care goals and a step-by-step plan to reach them. Care goals are aligned to specific chronic conditions and customized to each patient’s individual needs. 

The CCM clinicians will work on implementing specific, measurable, achievable, relevant, and time-specific (SMART) goals for the patient. For example, a provider might recommend that a patient with diabetes check their blood sugar after every meal and record it. Their CCM team can then help them create reminders to check their blood sugar or set up a daily journal to record their readings.

When the CCM care coordinator and the patient connect each month, the coordinator will check on the patient’s progress and record any updates in the care plan. The patient’s provider and the patient can view that plan at any time, so everyone is involved in the patient’s progress.

Why is a CCM care plan important? 

A CCM care plan is important because it can: 

• Help the patient and all of their providers share information
• Ensure patients’ updates are addressed monthly
• Improve patients’ health outcomes
• Encourage providers to account for Social Determinants of Health

Help the patient and all of their providers share information

A CCM plan can help close care gaps, especially when there are multiple conditions and providers involved in a patient’s healthcare. All professionals in a patient’s network–primary care providers, specialists, and care coordinators–need to know about changes in the patient’s conditions or in the treatment they’re receiving. The care plan can act as the center of this information workflow.

Ensure patients’ updates are addressed monthly

Through Chronic Care Management, patients work with their CCM team monthly to ensure they’re moving toward their health goals. 

CCM teams must devote at least 20 minutes of clinical staff time to each patient, per month. If the care coordinator reaches the patient on the phone, they might perform health assessments, check in on patients’ goals, set new goals, or ask patients questions about their symptoms. 

If they can’t reach the patient, the CCM care coordinator can instead update the patient’s care plan, communicate with them digitally, request updated records from other providers to load into the care plan, or gather health information and resources to send to the patient. 

Whether the patient answers the phone or not, they experience a strong connection to their providers every month. 

Improve patients’ health outcomes

Patients who have the skills and knowledge to improve their health and strong connections with their providers often have better health outcomes. The CCM care plan gives patients information about their conditions, specific goals to work toward, and strategies they can use to manage their health. 

When patients have detailed information about their conditions–whether that comes in the form of brochures, online articles, phone conversations, or videos–they can take charge of their overall health. They’ll know what steps they can take to slow the progression of their disease and to continue enjoying their lives, how to cope with their symptoms, and when they need to get in touch with their providers. 

Chronic Care Management also gives patients a sense of accountability while they work toward their health goals. Knowing they have a care coordinator who cares about their progress and will check in on them can help patients stick to healthy habits and improve their overall health. 

Encourage providers to account for Social Determinants of Health

Social determinants of health (SDOH), like economic stability, social and community context, and access to healthcare, have a dramatic impact on health outcomes. 

Care coordinators can talk to patients about whether they have access to essential resources like safe housing, healthy food, and transportation. They can also conduct regular SDOH screenings that assess for risk or gaps in care. 

If patients report that they’re struggling with any Social Determinants of Health, their care coordinator can connect them to organizations in their local area that might be able to help. In the past, ChartSpan care coordinators have connected patients with organic food delivery, car services, and exercise groups for seniors, among other resources. 

Using Chronic Care Management Care Plans

A comprehensive Chronic Care Management care plan gives providers and patients quick access to the patient’s medical history, conditions, and health goals. The plan also includes concrete strategies the patient can employ to reach those goals. 

But the care plan is just one element of how CCM helps patients connect with their providers and improve their health outcomes. To learn more, check out our case study with a Chronic Care Management client who saw nearly 50% of their eligible patients enroll in CCM.

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