Chronic Care Management (CCM) may be one of the hottest new opportunities out there for diabetes educators. CCM is a Medicare funded program since 2015, and more recently by some commercial insurers. It targets the highest risk demographic of an internal medicine or primary care practice, namely those with at least two chronic diseases including diabetes, hypertension, COPD, cancer and depression. Rarely, would you find someone with only one of these conditions at a time.
While medication management is not a chronic disease, it is also included in this list, as it frequently results in hospital admissions and readmissions for someone whose medication financial burden prevents them from being able to comply with their medication regimen. Homelessness and poor access to transportation only compound the problem. The chronic care manager role is to navigate the patient through every dimension/challenge of their healthcare journey. Most patients are seen four times per year by their primary care physician per Medicare guidelines. Life happens in between, however, and the CCM program can address those gaps.
The program involves monthly phone contacts with patients who have been identified with at least two comorbidities and referred by their doctor to the program. At any time they may choose to opt out but most find the monthly connection with their healthcare provider’s staff a good thing. Chronic care managers can expedite same day acute visits in the office to prevent a costly (both time and dollars) trip to the emergency room. The relationship between the chronic care manager and the patient is one built on trust; however, the patient also realizes early on in the process that he/she has a role in their healthcare, and the monthly call grows their confidence to be better advocates for themselves as they become more educated about their medications and what to expect at their office visits. The challenges are no longer overwhelming.
The Center for Medicare & Medicaid Services (CMS) says that CCM programs have been associated with better health and patient satisfaction, as well as an improved bottom line. That goes without saying if the patient is no longer a frequent flyer through the emergency room or urgent care centers. Beginning in 2017, CMS also implemented separate payment for complex chronic care management using CPT codes 99487 for 20-minute sessions and 99489 for 60 minutes.
CCM is the perfect model for the notion that “it takes a village” to keep people healthy and safe. Communication between the patient, the chronic care manager and ultimately the medical provider is the lifeline and a sure thing to managing the chronically ill person as a team.
Ask your doctor today if his/her office has a CCM program in which you or a family member can enroll. Better yet, consider your skill set and the possibilities as a diabetes educator in the role of a chronic care manager. This is the true essence of population health.
Submitted by: Nina Pletcher, MEd, RD, CDE
Member, DE LNG