The numbers tell the story. Some 85 percent of health care spending goes toward patients with chronic illnesses. About 25 percent of the general population has one or more chronic conditions, and that number jumps to 68 percent of people 65 and older. Some 60 percent of Medicare patients with chronic conditions are hospitalized each year. Hospital readmissions among people with chronic illnesses are 30 percent higher than the rest of the population; and of the $26 billion Medicare spent on readmissions in 2014, $17 billion was considered avoidable.
The story that this tells is that our system for caring for people with chronic illnesses isn’t working. Readmission rates are one of the tell-tale signs that the sick are getting sicker, and if more than half of that is avoidable, something is going wrong.
This is one of the key reasons the Centers for Medicare and Medicaid Services (CMS)–the agency that determines what Medicare will pay for, introduced a dramatically changed model for Chronic Care Management (CCM) in 2015. It’s flown mostly under the radar as practitioners struggle to understand it and put CCM into practice, but it’s part of a new “patient-centric” model designed to improve the health and quality of life of people with chronic illnesses.
People with chronic illnesses, especially with multiple chronic illnesses, tend to see lots of doctors, take lots of medications, and visit lots of facilities. None of these providers has the infrastructure or incentive to communicate with one another, leaving the patient or caregiver to manage it all and make it all work together. These are the people least equipped to manage it all.
CCM was introduced to enable and reward a patient’s primary doctor for becoming a leader of a team that connects all providers–specialists, therapists, pharmacists and in-home nurses and caregivers. They all participate in comprehensive, coordinated plan of care for each patient, and centralize communication and record keeping. Doctors are reimbursed for “non face-to-face” communication with patients twice each month. This means the doctor or a clinical staff member can check in with a patient on the phone, computer, and mobile device to monitor the patient’s condition. The frequency of communication has been shown to have a very strong correlation with a reduction in hospital visits.
Quality of Life
Patients also undergo a thorough monthly review that assesses the entire care plan, including medication management and adherence. Medication mismanagement results in 3.5 million hospital visits each year.
To be chronically ill means that you’re going to be dealing with your illness for at least one year or more. CCM is not just for the elderly, or just for people with incurable conditions. It is for anyone with multiple long-term issues from depression to heart disease. It is, of course, everyone’s desire that these conditions get better and not worse, and that a patient’s quality of life during treatment is as high as possible.
That’s the goal of CCM. Hospital admissions typically indicate that things are getting worse, not better. CCM can play an important role in keeping your loved one out of the hospital and in overall better health. To learn about CCM, contact your doctor, hospital, or pharmacist–all are key players on CCM teams. It’s a relatively new standard of care that incentivizes all stakeholder to provide better preventative care for the chronically ill.