Care Management: In-Between Visit Care.
Providing chronic care management for people with multiple conditions has traditionally been delivered in discrete units, otherwise known as visits. A person with hypertension, diabetes, kidney disease, arthritis, cataracts and hypothyroidism might see their healthcare provider 2-4 times per year. But what happens to that person in between visits? All too often the answer may be not enough.
We know that up to 80% of Medicare beneficiaries have multiple chronic conditions. We know that over 71 cents of every healthcare dollar spent in the U.S. is spent on those with multiple chronic conditions. We know that increasing numbers of chronic conditions are directly correlated to hospitalization rate, rehospitalization rate, nursing home placement and total medical spend. Until recently, we relied upon infrequent visits almost exclusively to provide care to these patients.
What people with multiple chronic conditions need is to keep “the train on the tracks” in between visits. People frequently watch what they eat and exercise for a few days before a doctor’s appointment, or brush their teeth and floss vigorously before a dentist’s appointment—in an effort to put their best foot forward before they see their healthcare provider. What people with chronic conditions really need is engagement with their health in between visits—an area that we often refer to as the “white space” in healthcare. We must do a better job helping our patients fill their white space with engagement tools, understanding of their chronic conditions, self-assessment, and a holistic, goal-directed approach. We must understand what each patient wants so we can deliver the care they need.
The Center for Medicare and Medicaid Services’ Chronic Care Management program, launched in January of 2015 can do just that. As part of the program, every patient has a comprehensive, goal directed care plan built. Practices can develop tactics to better address some of the “low hanging fruit” in chronic disease management, such as reminders of the importance of regular primary care visits, medication adherence, routine medication reconciliation, advanced care planning, and providing care coordination and help with care transitions. As a practicing physician myself, I fully appreciate the importance of each of these “low hanging fruit”, but admit that before CCM, I wasn’t always as systematically focused on them as I could have been. Here at Chronic Care Management, LLC, we are singularly dedicated to helping patients and practices achieve success with CCM. Together, we are transforming the “white space” in healthcare.
William Mills, M.D.
President & CEO