The Journey to Better Patient Outcomes: Why a Service Delivery Approach to CCM Makes Clinical Sense

As physician practices start to familiarize themselves with the Chronic Care Management (CCM) program introduced last year by the Centers for Medicare and Medicaid Services (CMS), a number of questions will spring to mind. Perhaps the most obvious are: How will I manage the additional workload and what will the infrastructure cost me, which were addressed in my last blog. The next question might be: does it make sense for me to seek help, and what does that actually mean to my relationship with my patients?

By Lisa R. Esch, Population Health Innovation, CSC

The role of the primary care physician is to care for and interact with patients to improve their health outcomes, but as I discussed, CCM is not a traditional model of care since it’s an out-of-office service, and so adopting a new model could be significantly more efficient and productive.

In fact, the shift in terms of using an external healthcare service to provide care to the patient is not unprecedented – it’s actually the direction in which healthcare is moving. More and more we see teams or networks providing care for the patient. A prime example of this is the shift to using hospitalists for the general medical care of hospitalized patients, allowing the primary care physician to be where their skills are best utilized – in the primary care practice managing patients.

The Next Logical Step

Having a service delivery team provide CCM support for the patient as part of the overall care journey is the next step. It adds support in terms of helping patients deal with chronic illnesses, freeing physicians to focus on clinical care and allowing care managers and care coordinators to guide the patient through the complexity of the healthcare system.

WESTF018673From the physician’s point of view, a CCM service should focus on closing the loop on communication by sharing the patient’s care plan through a central repository. That’s an important and often overlooked factor.

The issue of care-wide communication and coordination has long been a challenge after the patient leaves the hospital. For the most part, the physician was responsible for the follow up, but as they see increasingly more patients and manage more and more complex diseases in their office, follow-up between patient visits is a significant challenge.

Moving the coordination of care to a service delivery team reflects a proactive approach, through communication and education, to help physicians navigate their patients’ health challenges, rather than waiting for patients to call due to potentially declining conditions. It’s about staying ahead and minimizing the risk of escalating health problems.

Reasons behind the Program

One of the key reasons why CMS introduced the CCM initiative is to reduce avoidable re-admissions and utilization of costly in-patient services. The goal of care coordination is to help patients stay compliant, stay on their care plan and stay healthy. Having a service delivery team manage the monthly conversation with patients and conduct follow up with physicians’ offices creates a critical link in the chain. It provides a support service to monitor the patient if conditions worsen or problems arise. Enabling digital technology is integral to managing the patient oversight and the communication back to the physician. Patient data, e.g., whether the patient is recording their blood sugars, is accumulated and that data is constantly monitored.

Patient-driven data and data from the physician’s office are used to monitor the patient’s status, to assess potential trends that require intervention, and then to make recommendations on patient care. It could mean a recommendation to see their physician sooner rather than later in order to avoid the potential of a visit to the emergency room. The point is to pre-empt serious consequences and direct the patient to the right avenue of care before it turns into something that needs hospital admission.

While the CCM initiative is directed at primary care physicians who enroll their patients in the program, it has relevance to hospitals for a number of reasons. First, hospitals have funded and established primary care practices where the hospital and primary care doctor collaborate to reduce readmissions. Second, it behooves hospitals to ensure patients are following a care coordination plan once released from the hospital to avoid readmission, since it’s the hospitals that are penalized by Medicare for that readmission. CCM, therefore, makes sense for the entire health care system.

In my next blog, I’ll address how primary care physicians can have the conversation with their patients to help guide them into a CCM program and improve their long-term health outcomes.

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