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Chronic Care Management

The American government reports that nearly 25% of the adult population and 75% of seniors have several chronic diseases. They are not only common but also extremely expensive to manage, accounting for more than half of all healthcare expenditures. Most of the patients generally cannot afford to pay for treatment, they also show low motivation resulting in low engagement in the therapy.

chronic care management

Medication Management

Lifestyle changes for some chronic conditions can be effective enough to avoid complications while others require regular medication. The medication regimen for patients with several chronic conditions is often an important aspect of their treatment and long-term health. Though medication adherence and compliance are not exclusively the responsibility of the patient, his engagement is key to maintaining his health and well-being.

Chronic Condition Management

Chronic condition management is challenging for both provider and patient. The more chronic conditions a patient has, the greater the risk of hospitalization increases. Such a patient also requires frequent visits to his physician and receives more extended care as compared to what is typically required for an acute condition. Coordination between all medical professionals involved is another factor affecting the patient’s health. Care fragmentation results in a higher risk of complications due to conflicting recommendations and so forth.

medication management

Care Management And Population Health

Starting from 2015 physicians started to receive payments under the chronic care management program (CCM) for treating Medicare beneficiaries with two or more chronic conditions. After the first 1.5 years since the model was adopted, there was a remarkable decrease (by $74-95 per patient) of total monthly spending.

CCM starts with the patient’s willingness to participate. After the agreement is signed, the patient may expect 24/7 access to services, the same physician for appointments, a patient-centered treatment plan, an electronic record of his health data, and enhanced communication to receive needed advice or information. Outside of the physician’s office, CCM aims to support the self-care of the patient. More emphasis is placed on individual behavior, such as the patient’s responsibility and motivation to manage his condition more independently and effectively.

Though adoption of the CCM program is challenging due to billing confusion, the necessity of electronic records, and fears that documentation will be time-consuming, the program is an advancement in treatment.

Solve.Care is one of the leaders in providing solutions for CCM, as evidenced by the recent project in diabetes management in collaboration with Boehringer Ingelheim Pharmaceuticals, Inc. Dr. David Hanekom, the Chief Medical Officer and Regional President, North America of Solve.Care said: “Empower patients with health information and personal clinical decision support in a manner that allows them to understand their health challenges, benchmark the care they receive against evidence-based professional guidelines, and seek out service providers that can help them achieve best outcomes at an affordable price. Our industry has become adept at data analytics and providing clinical decision support to healthcare providers, but have not done the same in providing the same information to the patient, who ultimately will bear the consequences, good or bad, of any and all healthcare decisions made by or on behalf of the patient”.

Chronic care management and population health improvement is a new direction for the healthcare system. Existing models have shown their insufficiency, forcing the whole industry to shift toward preventive treatment and patient-centered care. CCM is a part of this process. By placing the patient at the center, enhancing his engagement in the therapy, and supporting his self-management, CCM has shown better effectiveness compared to other models: compilations are detected faster and patient’s compliance with the medication regimen, as well as his motivation and engagement in the treatment have improved. Considering the prevalence of chronic diseases in the United States, CCM contributes equally to individuals and public health.

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