What is the primary feature to consider when developing a chronic care management (CCM) service for patients with 2 or more chronic conditions?

Developing Chronic Care Management Services for Patients with Multiple Chronic Conditions

The most effective feature to consider when developing a chronic care management (CCM) service is implementing a proactive delivery system design that moves from reactive care to planned, coordinated team-based care. 1

Key Elements of Effective CCM Service Development

Delivery System Design

• Transform from reactive to proactive care through planned visits coordinated by a team-based approach 1
• Implement care management teams including nurses, dietitians, pharmacists, and other providers to support primary care physicians 1
• Focus on timely and appropriate intensification of lifestyle and pharmacologic therapy for patients not meeting goals 1

Patient Eligibility Requirements

• Ensure proper identification of eligible patients who have 2+ chronic conditions expected to last at least 12 months
• Target patients at significant risk of morbidity and mortality, as this aligns with Medicare requirements and maximizes impact on health outcomes 1
• Use clinical information systems and registries to identify and track these high-risk patients 1

Self-Management Support

• Incorporate structured patient education and self-management support 1
• Engage patients in explicit and collaborative goal setting to improve outcomes 1
• Address barriers to care including language, numeracy, or cultural factors 1

Clinical Information Systems

• Utilize electronic health record tools to track patient progress and provide decision support 1
• Implement patient registries that provide both patient-specific and population-based support to the care team 1
• Design systems that facilitate coordination across care settings 2

Implementation Considerations

Team-Based Approach

• Redefine roles of clinic staff to support CCM implementation 2
• Avoid therapeutic inertia by prioritizing timely interventions for patients not meeting targets 1
• Ensure care teams are prepared for implementation through proper training and support 3

Evidence-Based Care

• Base care decisions on evidence-based, effective guidelines 1
• Integrate clinical information tools into the process of care 1
• Provide structured care through guidelines, formal case management, and patient education resources 1

Financial Considerations

• Understand reimbursement mechanisms for CCM services
• Note that while codes are available for clinical staff, primary care providers cannot bill for work performed personally
• Consider that a 5-year study of CCM implementation showed healthcare savings of $7,294 per individual 1

Pitfalls to Avoid

• Patient Enrollment Issues: Avoid automatic enrollment without proper consent; Medicare beneficiaries must opt-in, not opt-out 2
• Supervision Requirements: Ensure appropriate supervision structures are in place without requiring direct supervision for all services
• Fragmented Care: Prevent duplication of services through proper coordination 1
• Neglecting Social Determinants: Address financial barriers and psychosocial issues that impact chronic disease management 1

Impact on Health Outcomes

Implementation of the CCM has been shown to significantly improve health outcomes:

• 56.6% reduction in cardiovascular disease risk
• 11.9% reduction in microvascular complications
• 66.1% reduction in mortality 1

By focusing on a proactive delivery system design with team-based care, your chronic care management service will be best positioned to improve morbidity, mortality, and quality of life for patients with multiple chronic conditions.