Top Benefits of Chronic Care Management for Patients and Providers

The Role of CCM in Modern Healthcare

Complex comorbidities put patients at significant risk of functional decline, acute exacerbations, and even death. To ensure good outcomes for such patients, you need a way to manage care transitions, given the complexity of coordinating care for multiple chronic conditions.

CCM helps elevate care in such scenarios by providing infrastructure and frameworks for the following:

• Continuous relationship with a care team: With a centralized point of contact and an assigned nurse, CCM enables regular, proactive communication. The patient can get timely support when they need it.
• Reconciling various prescriptions: When patients use multiple medications prescribed by different specialists, CCM simplifies treatment interactions by centralizing medication lists and effectively managing care transitions.
• Care coordination: If you are the primary provider for a patient seeing multiple specialists, CCM gives you a central platform to coordinate care.
• Prioritizing pressing medical needs: When there are conflicting guidelines for managing a patient's multiple conditions, CCM gives you the tools to prioritize the most pressing needs while keeping the patient's overall healthcare goals and quality of life in view.

It's noteworthy that Medicare supports CCM. There are clear reimbursement guidelines, and billing is based on time spent on non-face-to-face services each month.

Core Benefits of Chronic Care Management

Effectively implementing a CCM program can have a transformative impact on your practice and patients.

Let's explore some of the key benefits of chronic care management as reported by providers nationwide and a growing body of research:

Increases Access to Care in Underserved Communities

Complex comorbidities require a holistic and personalized approach to care delivery to achieve good outcomes. However, provider shortages put patients in rural and low-income areas at a significant disadvantage.

While 20% of our population lives in rural areas, only 10% of providers live there. The provider-to-patient ratio is even more alarming for specialized care, with rural areas having 30 specialists per 100,000 people. In contrast, urban areas have 263 specialists per 100,000 people.

CCM is stepping up to help address these distance-to-care and provider-to-patient ratio problems. It combines technology solutions with skilled clinicians to remotely provide dedicated personalized care to patients wherever they are.

Significantly Lowers Readmissions and ER Visits

CCM is a highly effective proactive care management model, which leads to fewer reactive readmissions and ER visits.

Because CCM includes regular non-face-to-face check-ins, your care team has up-to-date information about your patients' conditions and can spot red flags before they escalate.

Further, combined with Remote Patient Monitoring (RPM), you can remotely collect and transmit patients’ physiological readings.

RPM platforms will typically notify you when vital signals are out of range. KangarooHealth, for instance, comes with tailored escalation protocols so you can quickly attend to serious issues that warrant an immediate escalation.

Lowers Costs for the Provider and Patient

High-cost events like readmissions and ER visits weigh down both providers and patients. Since they are significant resource burdens, reducing hospitalizations can significantly reduce healthcare costs.

For instance, a Medicare-commissioned study of CCM found that patients under CCM had significantly lower hospitalization rates, used ER services less often, and (excluding those who only received one month of CCM) cost Medicare $95 less per month.

In another study evaluating whether telemonitoring can reduce hospitalizations, the odds of experiencing 30-day and 90-day readmissions for the telemonitoring group were 44% and 38% lower, respectively.

The lower hospitalization rates translated to an approximate 11% cost savings for the payor.

Enhances Provider Accountability

Effectively planning a CCM implementation requires clearly defining roles and responsibilities within your care team. It becomes much easier to track tasks or progress and hold everyone on the team accountable for their part in patient care.

Also, with tailored escalation protocols, you can define clear communication channels so that every relevant stakeholder is informed at each escalation stage. A bonus benefit of designing escalations this way is reducing alert fatigue, as only the right people are involved at each stage.

Improves Patient Engagement and Satisfaction

With a dedicated care team always in contact with the patient, a trusting provider-patient dynamic develops where the patient feels they have a caregiver who is invested in their well-being and health outcomes.

CCM and other remote patient care solutions also make patients active participants in their healthcare journey, greatly enhancing personal satisfaction.

Many of your patients will appreciate being under CCM. A report evaluating the diffusion and impact of CCM services offered some insights into how patients feel about CCM:

• Some patients noted that they were talking with the same nurse every time and appreciated the care continuity.
• Several patients noted that CCM had improved coordination across their care team.
• Many patients appreciated being in contact with a nurse who could schedule an in-person appointment much quicker than they could have independently.
• Patients described the check-ins as “reassuring” and “a good reminder.”
• Several patients felt that regular calls spared them from unnecessary office visits.
• One patient described the monthly check-ins as having helped him and his wife to remain mindful of their health.

Chronic Care Management Implementation

You want to have a solid CCM implementation plan to ensure the program is compliant, operationally efficient, and effective.

You'll typically need to prioritize the following activities:

• Define program goals and plans: Setting program objectives is vital. Which patient populations are you targeting? Are there specific quality metrics you want to improve? How do your current workflows fit within the new plan?
• Build a multi-disciplinary team: CCM requires expertise from several specialists. You can outsource some non-face-to-face roles to a platform provider, which has in-house nurses.
• Onboard a CCM platform: You'll need a remote patient care platform with CCM services. KangarooHealth supports over 50 chronic conditions and comes with a multilingual clinical team, omnichannel communication, and billing support.
• Identify and enroll patients: You will need your patients’ consent before enrollment. Identify eligible patients, enroll them, and provide comprehensive training and education to set them up for success.
• Operation and optimization: Each patient needs a personalized care plan. Also, you must have at least 20 minutes of non-face-to-face staff time with the patient per calendar month to meet the reimbursement threshold. You must routinely measure impact and monitor the program to ensure it meets its objectives.

For good outcomes, you want to implement CCM with a platform partner that can adapt to the unique needs of providers and patients.

KangarooHealth provides disease-specific care management templates for intake and follow-up and adapts to your needs so you can provide personalized chronic care at scale.

Also, we handle the setup process so you can focus on patient care. Schedule your free demo today to discover how KangarooHealth's proven remote patient care solutions can transform your practice.

Long-Term Impact of Chronic Care Management

CCM is already helping providers shift from reactive and episodic healthcare delivery to a sustained proactive one. Patients with multiple chronic conditions are not only living better as a result, but they are also living longer.

Here are some of the long-term impacts of CCM:

• Contained disease progression: With constant monitoring, personalized interventions, and higher adherence, CCM provides a robust mechanism to manage comorbidities. Over time, it may help slow the progression of chronic diseases.
• A longer, higher-quality life: CCM helps patients gain control over their life and healthcare journey. Because of better disease management and healthier lifestyle choices, there's less emotional stress, complications, and severe symptoms, significantly enhancing the quality of life.
• Improved in-person care: Without remote patient care capabilities, all your patients must visit the office for reviews and treatment adjustments. CCM allows you to reduce in-person visits significantly, freeing more staff time and resources for patients who really need in-person attention.

Notably, as value-based care (VBC) expands going forward, programs like CCM that prioritize quality of care and patient outcomes equip providers with the skillsets they need to succeed in the future.

The Future of Chronic Care Management

Chronic care management will only get better with time. So, what does the future of CCM look like?

Here's what we'll likely see more of:

• Greater integration with RPM: KangarooHealth already offers an all-in-one CCM platform with RPM and other services like Principal Care Management (PCM). With time, we'll likely see more RPM devices being able to feed data into CCM systems.
• AI-driven predictive analytics: AI will likely play a bigger role in CCM. With greater integration with RPM, CCM platforms will have adequate real-time data to feed into predictive AI models that can flag adverse events before they happen.
• Greater interoperability: Many CCM platform providers have business models tied to their device manufacturing businesses. They limit interoperability to facilitate cross-selling and lock in recurring revenue. As value-based care matures and business incentives change, we'll likely see greater interoperability in the sector.
• Improved patient-specific optimization: AI, RPM technology, and genomic data will likely make hyper-personalization of CCM technologically and financially feasible in the future. We may see care plans being updated in real-time, data-driven AI coaching, and context-aware lifestyle modification recommendations.

Frequently Asked Questions (FAQs)

Let's now answer some of the common questions we get about chronic care management:

What Is the Minimum Requirement to Enroll in Chronic Care Management?

Medicare has the following requirements for enrollment into CCM programs:

• There should be a significant risk of functional decline, acute exacerbations, or death.
  The patient can only enroll in a CCM program with only one provider at a time.
• For new patients, an initial face-to-face visit is required.
• The patient must have two or more chronic conditions.
• Patient must consent to join the CCM program.

How Is Chronic Care Management Different from Case Management?

While case management focuses on solving a specific episodic problem and is often reactive, CCM is a continuous, proactive approach to managing chronic conditions for the long term.

Can CCM Be Provided in Rural or Remote Areas?

Yes, CCM would be a game-changer in underserved populations such as rural areas. Rural communities face several healthcare provision problems, including distance to care, provider shortages, limited connectivity, and lower health literacy.

CCM can help solve these problems. Moreover, cellular-powered devices ensure you can collect and transmit patient data without patient-provided Wi-Fi.

What Documentation Is Required for CCM Billing?

You must create an auditable record demonstrating the patient's eligibility and the existence of a CCM care plan. You’ll need to track activities and time spent providing care under CCM.

KangarooHealth automates activities and clinical time tracking. You'll also find navigating CPT codes a lot easier with our platform.

Conclusion

Embracing CCM is becoming a necessary step in providing patient-centered care for those with multiple chronic conditions. It helps providers reach underserved communities, effectively coordinate care, improve engagement and adherence, and significantly reduce adverse events.

With KangarooHealth by your side, you can now implement CCM in your practice to deliver personalized care at scale.

Aside from providing a robust remote patient care platform, we also handle device procurement and distribution, staff and patient training, billing support, and continuous patient support with multilingual nurses.

Talk to our team today to see how our comprehensive remote patient care solutions can transform your practice.