Below is a Typical Model of a Chronic Care Management Program
There is a recipe for improving quality that involves evidence-based guidelines , system change strategies and quality improvement methods. You are all familiar with evidence-based guidelines, so let’s start with the system change strategy.
The Chronic Care Model (CCM) is an organizational approach to caring for people with chronic disease in a primary care setting. The system is population-based and creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team.
The CCM identifies essential elements of a health care system that encourage high-quality chronic disease care: the community; the health system; self-management support; delivery system design; decision support, and clinical information systems. Within each of these elements, there are specific concepts (“Change Concepts”) that teams use to direct their improvement efforts. Change concepts are the principles by which care redesign processes are guided.
The items below are the change concepts associated with each component of the model that, when implemented, result in improved patient and system outcomes.
So What Does All This Mean?
Successful system change means you will redesign care within each of the six components of the CCM; it does not mean tweaking around the edges of an acute care system not capable of handling the needs of the chronically ill. You will be building a new system that works in concert with your acute care processes. You will accomplish this by testing the above change concepts and adapting them to your local environment. The remaining steps in this manual help focus where you can start making these changes.
Tools That Can HelpAfter learning more about the chronic care model, there are two things that may assist you in understanding how it directs system change. The first is the Assessment of Chronic Illness Care, which is a diagnostic survey that you and your team can complete together. The ACIC helps you identify that current state of your chronic care; what’s working and what is needed to achieve redesign in all components of the CCM.
The other tool is the ACT Report [PDF] (Shoeni, P. Accelerating Change Today: Curing the System, May 2002). This report provides concrete examples of teams that have redesigned their care based on the CCM. Some of the stories and the practices they represent may resonate with you and your team.
There Needs To Be a Quality Improvement Process
This is the final ingredient in the recipe. The Model for Improvement is a simple yet powerful tool for accelerating quality improvement changes in your organization. Developed by Associates in Process Improvement, the model has two parts. In the first part, your team will address three fundamental questions. These questions will guide your team in creating aims, measures, and specific change ideas. Secondly, your team will use Plan-Do-Study-Act (PDSA) cycles to allow these changes to be easily tested in your work environment.
CHRONIC CARE MANAGEMENT
An estimated 117 million adults have one or more chronic health conditions, and one in four adults have two or more chronic health conditions. Through the Connected Care campaign, the CMS Office of Minority Health and the Federal Office of Rural Health Policy at the Health Resources & Services Administration will raise awareness of the benefits of CCM for patients with multiple chronic conditions and provide health care professionals with resources to implement CCM.
The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions.
Less than 3% of all elegible Medicare Patients have enrolled in a CCM Program and less than 2% of all Providers have offered these services.