Chronic Care Management
Colorado Pain Management
Chronic care management (CCM) is a major component of primary care that
promotes better health and reduces overall healthcare costs. CCM is offered
to Medicare beneficiaries who suffer from two or more chronic pain conditions.
The service is performed over the phone or through email, allowing patients
to receive pain management advice without having to leave their home.
What does chronic care management cover?
Chronic care management covers phone calls, emails, management of referrals
to providers, ongoing review of patient status, and management of prescriptions.
The scope of services includes:
- Access to care management 24 hours a day and 7 days a week.
- Care management for chronic conditions, such as assessment of psychosocial,
medical, and functional needs, medication reconciliation, and approaches
to ensure preventive services are rendered.
- Creation of a patient-centered care plan document.
- Management of care transitions that includes referrals, follow-up after
emergency department visit, hospital, or other care facility.
- Coordination with community-based and home-based clinical service providers.
- Enhanced opportunities for patients and caregivers.
- Electronic capture and sharing of care plan data/information.
What conditions are treated under chronic care management?
Chronic care management is used for many chronic conditions, which include
but are not limited to:
- Degenerative disc disease
- Rheumatoid arthritis
- Inflammatory arthritis
- Multiple sclerosis
- Parkinson’s disease
- Cerebral palsy
- Complex regional pain syndrome
- Congestive heart failure
- Chronic pulmonary disease
- Autoimmune disease
Who participates with CMS’s chronic care management?
Practitioner eligibility includes physicians, nurse practitioners, certified
nurse midwives, physician assistants, and certified nurse specialists.
CCM may be billed by primary care practitioner and certain specialty physicians
and practitioners. However, CCM is not available for clinical psychologists,
dentists, or podiatrists.
What are the patient eligibility requirements for chronic care management?
- Patients with two or more chronic conditions, which are expected to last
12 months or until the death of the patient.
- Conditions that place the patient at significant risk of death.
- Patients who have functional decline, decompensation, or acute exacerbation
of a chronic illness.
What can I expect with a chronic care management service?
CMS recognize care management as an important aspect of healthcare that
should lower your overall medical expenses. Chronic care management requires
that the clinical staff spends at least 20 minutes per patient each month
to establish, implement, revise, and monitor a care plan.
What is in the chronic care management care plan?
The care plan is based on the patient’s mental, physical, psychosocial,
functional, and environmental needs. The details of this plan are consistent
with the patient’s choices and values. The patient-centered care
plan includes a plan for preventive services, oversight of medication
(compliance and reconciliation), and periodic assessment of patient’s needs.
What are the results and benefits of chronic care management?
The results/benefits of chronic care management include:
- Patient response and connectivity – Patients enjoy chronic care management,
and response rate has been good.
- Low effort and resource requirements – Patients under chronic care
management enjoy a dedicated team of caregivers who monitor medicines,
help with referrals, and work with healthcare facilities to improve overall