Chronic Care Management under Medicare offers additional help to patients who are managing chronic conditions like arthritis, diabetes and hypertension. This includes a comprehensive care plan that lists all of your health issues and goals, other providers, medications, community services you have access to and need, and other relevant information about your health. It also outlines the care you need and how your care will be coordinated. Your health care provider will ask you to sign an agreement to provide this service.
If you agree to get this service, your provider will prepare the care plan, help you with medication management, provide 24/7 access for urgent care needs, give you support when you go from one health care setting to another, review your medicines and how you take them, and help you with other chronic care needs. Chronic Care Management may be covered by Medicare if you have two or more serious chronic conditions that are expected to last at least one year.
Acute vs chronic illness
Chronic health conditions are conditions expected to last one year or more and therefore require ongoing medical care. These health conditions can limit a person’s ability to engage in day to day activities. Chronic illnesses are often costly. Nearly half of all people in the United States suffer from at least one chronic condition.
Common chronic health conditions include:
- high blood pressure or hypertension
- heart disease
- oral diseases
- respiratory or lung diseases
Medicare does not limit eligibility to a specific list of health conditions. Conditions that can qualify are expected to last at least 12 months, and are expected to increase the risk of the patient going to the hospital/clinic, long term disability, or loss of life.
Acute illnesses generally develop suddenly and last a short time which is often only a few days or weeks. Chronic health conditions develop slowly or gradually and may worsen over a long period of time, which can be months to years. 48% of the US population is living with at least one or more chronic illnesses. This number is vastly increasing over time and as a result, the US Health system allocates approximately 75% of its annual budget to chronic medical conditions alone. This strongly indicates that the healthcare system must adapt effective chronic illness management practices to monitor conditions.
What is Chronic Care Management?
A person with multiple chronic health conditions may benefit from tailored health services that focus on coordinating and directing care. Chronic Care Management or CCM is normally covered under the Medicare Part B benefit and is for patients who have two or more chronic conditions.
The CCM program provides assistance for a person to manage their health from within the community and can lead to greater outcomes and increased quality of life. A healthcare provider will identify any patients who qualify for Chronic Care Management under Medicare. A doctor, nurse practitioner, or physician assistant will then work with the patient to develop a suitable and tailored care plan.
The plan usually includes:
- the main health concerns
- healthcare providers who are needed and will be involved
- details of prescribed medications
- any community services required
The patient must express interest and permission for receiving Chronic Care Management services by signing an agreement with their healthcare provider. The main goal is to maintain and improve the health and wellness of the patient, with services expected to be delivered every month.
Services included in Chronic Care Management
Some of the services that can be provided with Chronic Care Management plans include:
- health management services
- organizing and coordinating with other healthcare providers by phone, virtually, or in-person
- community resource referral, services, and support
- disease education to achieve health management
- health education, including health literacy
- management and coordination of prescription medications
- coaching for health and wellness
- interventions to reduce risk factors for falls
To qualify for Chronic Care Management, a person must have a face-to-face visit with a healthcare provider who offers the services. After signing their agreement, a person can cancel the plan or transfer the plan to another healthcare provider.
Alternatives to Medicare’s Chronic Care Management
Other community services aside from Chronic Care Management plans may also help coordinate medical care for chronic illness patients.
Those who qualify for Medicaid could also have access to community-based care. Furthermore, services under Medicaid include case management, in-home care, personal care, and transportation to various healthcare services.
The Program of All-Inclusive Care for the Elderly (PACE) is managed and provided by Medicare and Medicaid. The program aims to help organize the healthcare needs of older adults within their community. PACE centers must meet federal and state regulations and a team of healthcare providers from a PACE organization coordinates care.
To qualify for PACE assistance, a patient must. have Medicare, Medicaid, or both. They must also be aged 55 years or older and live in a PACE center service area. Patients should also have a state-certified need for nursing home care and be safe in the community when using PACE services.
Why is managing chronic illness important?
Tracking one’s chronic illness can help patients adhere to their treatment plan. Patients are able to see for themselves what aspects of their treatment plan are working well and which are not. Moreover, they are able to view the reasons for why certain aspects are working using recorded daily data.
Tracking your chronic illness can also lower costs and save time. As mentioned, chronic medical conditions cost the US health system 75% of its health care budget. Tracking can allow patients to identify and implement beneficial lifestyle changes that may prevent worsening of their condition.
Chronic illness patients must often cope with:
- symptoms and disability
- emotional impacts
- complex medication regimens
- difficult lifestyle adjustments
- physical, psychological, and social demands of their illness without much help or support from medical care (coping at home, outside of the hospital/doctor’s office)
- learning to be self-managers of their disease
- identifying credible resources for information about their illness and obtaining helpful medical care
Through tracking and managing their chronic illnesses, patients are able to identify potential triggers and relievers for their symptoms. Tracking your symptoms and habits on a daily basis can allow you to discover correlations. Increased knowledge about what helps and what does not can allow patients to better manage their health.
Importance of Chronic Care Management
People living with persistent health concerns or multiple chronic illnesses often have more extensive and complex healthcare requirements. Implementing a coordinated care model can contribute to better general health and wellness for these individuals.
In 2015, the Center for Medicare Services (CMS) recognized Chronic Care Management as a critical component of care for people living with two or more chronic diseases. Chronic illness is widespread. Half of all adult Americans have a serious chronic condition including arthritis, cancer, diabetes, heart disease, or dementia.
Chronic illness is also very costly. Approximately 85% of all healthcare spending in the United States goes to the treatment of chronic illness. One of the main reasons for this high cost, is expensive emergency room care and hospitalization. An estimated 30% of emergency department visits made by people living with chronic illnesses are unnecessary, leading to $8.3 billion in additional costs for the healthcare sector.
Self care is vital for effectively managing a chronic illness because patients can become more aware of their symptoms and potential irregularities. Chronic illness symptom tracker apps provide patients with a platform to track and monitor their conditions on a day-to-day basis. This ensures that they adhere to their prescribed treatment plans. Down the line, this can reduce potential costs associated with improper health management. Patients can also improve their knowledge regarding their personal health and become more aware of warning signs or triggers that are associated with their health conditions.
CareClinic, a free app for managing chronic illness
CareClinic is a free online platform that enables users to actively respond to their chronic illnesses. Users and their healthcare provider are able to create flexible and adaptive care plans. Patients can also track and manage all physical and psychological aspects of chronic conditions conveniently. Patients should record any symptoms and changes in their health. Users of CareClinic should also take note of which aspects of their treatment plan are working for them. Aspects of your health that can be tracked include physiological changes such as blood pressure and heart rate, physical activity, and diet.
CareClinic allows patients to easily record data and information about their chronic illness. The app provides value-based care which bridges the patient-physician gap by ensuring adherence to care plans outside of the doctor’s office or hospital. Furthermore, self-management apps like CareClinic allow patients to engage in proactive behaviors and take control of their health at all times.
Our platform assists in self-monitoring by using reminders, rendering useful reports, and keeping everyone in the loop. All of this has proven to improve outcomes and potentially reduce symptoms over time. Therefore, we encourage you to try CareClinic out for yourself. The app is free to download on iOS and Android by clicking here.
Why should chronic illness patients track their symptoms?
Increased patient engagement is associated with better health outcomes and increased quality of life. Chronic illnesses are long-term medical conditions that often progress gradually over time in severity and scope. In order to have the best quality of life, it is important to stay informed about your illness. Therefore, it is important that patients are more proactive, adopt sustainable lifestyle changes, and collaborate with their healthcare team.
Individuals with chronic illnesses face many obstacles in coping with their condition. This is because traditional healthcare systems often do not meet their needs for effective management, psychological support and information. Moreover, there is often a mismatch between the needs of patients dealing with chronic illness and healthcare systems that are primarily designed for treating acute illnesses.
Tracking chronic illness empowers patients to become self-managers and collaborators with their healthcare team. Patients become more informed about their health and have a better understanding of their illness. Therefore, they are able to assist their care team in identifying which management strategies and treatment options work best for them.
How to use CareClinic as chronic illness tracker
CareClinic is a comprehensive tool for adequate medication management. It allows you to bring together your medical information, health data, and ongoing treatments. Therefore, you can remain informed about all aspects of your health.
The app can be used as a pill lid tracker, alleviating the stress and task of manually timing your medication intakes. Furthermore, it highlights potential drug interactions and offers a health journal to document different aspects based on your personal diagnoses.
The application is available for free and can be used on various smartphones and even computers. It complies with the current privacy laws and safeguards your medication information. Moreover, the app seamlessly performs through a sleek and innovative user-friendly interface. CareClinic can assist both patients and physicians in improving medication management and adherence to complex treatment plans.
After signing up with the app, you can add your chronic disease. Then, record the medications that you use and any interventions in your Care plan. You can include your medicine, natural remedies, physical activity, therapies, and even your diet. Record your symptoms when they increase or decrease. You should also include any associated activities or triggers.
Remember to set reminders for your medicine which helps to ensure that you are taking your medications at the right times and in the right dosages. You can also set reminders to ensure that you take certain medicines at the right times and in the right amounts
Find correlations in the reports. Therefore, you can see what is working and what is not from the simple graphs and reports created by the app. Share or print your reports for a caregiver or your doctor who is part of your Chronic Care Management plan. These reports provide them with more accurate details about your health and progress.
Chronic Care Management Programs
Chronic Care Management programs combine three key elements of care to help patients manage their chronic health conditions. These elements are care between visits, preventative care and remote care.
Care in between visits aim to increase patient compliance by using provider recommendations between their office visits. This increases the focus of the patient on their general health and wellness. In between visit care also allows for healthcare providers to continuously monitor the health status of patients outside of the practice walls.
Preventative care increases patient compliance to various health interventions, such as the flu shot. It also increases healthcare provider’s ability to identify new health concerns and complications faster and sooner. Engaging in preventative care may also help to increase provider compliance with quality measures. Remote care increases the ease of access to wellness resources and lowers the barriers for continued engagement in care. Remote care may also free up providers and staff to focus on in-office encounters.
Medicare considers patients eligible for Chronic Care Management if they have multiple (two or more) chronic conditions expected to last at least one year. Common chronic conditions include arthritis, asthma, diabetes, COPD, high blood pressure, and heart disease.
Use of technology in managing chronic illness
Chronic illness symptom tracker apps like CareClinic empower patients to learn more about their health. In this way, patients are able to effectively manage their symptoms. Technology has revolutionized the healthcare industry. For instance, healthcare apps have made it easier for patients to become more involved with managing their healthcare. While healthcare apps do not replace key in-person interventions facilitated by healthcare professionals, they can aid in improving one’s personal health management and knowledge about their health. Health apps for dealing with chronic illness assist individuals in identifying potential risk factors and relievers that are associated with their symptoms.
Most importantly, technology has been a key contributor for the push towards personalized medicine. Personalized care plans can be curated on these online platforms specifically for the patient and their health journey. In this way, patients are able to easily collaborate with their healthcare provider to design care plans that work for them. Therefore, this approach to medicine can aid in the management of existing chronic conditions. This approach can also alert patients of potential ailments, delay complications or positively prevent the development of a chronic illness.
CareClinic is an all in one healthcare management tool and allows users to track all aspects related to their wellness in one place. With only one tap, all information pertaining to your personal chronic illness care plan is available! The app is an extremely convenient way to oversee your health conditions.