What Is Chronic Care Management?


According to the U.S. Department of Health and Human Services (HHS), roughly 70% of adults over age 65 will eventually have a crucial need for some form of long-term care. Chronic illnesses, in particular, are likely to call for more intensive, specialized medical services and daily assistance on an ongoing basis.

If you or someone dear to you are suffering from Alzheimer’s disease, symptoms of diabetes, cancer, multiple sclerosis, heart disease, Parkinson’s disease, or another severe illness, we encourage you to consider chronic care management.

What is chronic care management, who is it for, and how does it work? Alliance Homecare in New York is here to answer these questions and provide insight into what a chronic care plan might look like.

What Is Chronic Care?

Chronic care management (sometimes called CCM or chronic care) provides patients with additional assistance in managing chronic health conditions and illnesses. It typically involves a comprehensive care plan that takes into account all medical issues, medications, and health care providers to create a coordinated effort to achieve better outcomes.

This type of in home nurse care is recognized by the Centers for Medicare & Medicaid Services (CMS) as a vital component of primary healthcare. The federal agency characterizes it as “is care coordination services done outside of the regular office visit” for patients with chronic conditions who require assistance for at least a year.

Acknowledging that nearly 120 million adults in the U.S. have at least one chronic health condition, CMS is raising awareness for chronic care management. The agency’s Connected Care campaign strives to demonstrate how crucial it is not just for the health of Americans but also for minimizing medical costs in the long run.

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What Is Chronic Care Management For?

So, what is chronic care management for, or rather, who? CCM is often recommended when a serious medical condition (or multiple conditions) puts a person at significant risk of severe functional decline, worsened preexisting conditions, acute decompensated heart failure (ADHF), or death.

These health conditions include (but aren’t limited to) arthritis, heart disease, diabetes, cancer, kidney disease, multiple sclerosis, ALS, stroke, cardiovascular disease, osteoporosis, organ failure, severe mental health conditions, and Alzheimer’s disease. 

Definitionally, a chronic condition:

  • Lasts a year or more
  • Inhibits a person from performing daily self-care activities
  • Requires ongoing medical care

According to the CDC, about 60% of Americans suffer from a chronic disease, and 40% have more than one. If you or a loved one are among the millions of aging adults with a severe health disorder or debilitating disease, a CCM plan might be the best course of action.

How Does Chronic Care Management Work?

A chronic care management plan usually involves collaboration among doctors, physician assistants, nurse practitioners, and clinical staff nurses. Patients receiving at-home CCM through a licensed home care services agency (LHCSA) such as Alliance can also get assistance from a home health aide.

Chronic care management often involves:

  • Ongoing plan coordination
  • Medication management and reminders
  • Around-the-clock urgent care access
  • Assistance getting to healthcare appointments
  • Support for ADL (activities of daily living)

Ultimately, a high-quality CCM plan can help reduce chronic pain, improve mental and emotional health, support a better recovery, and offer peace of mind for patients and their families.

If you have Long Term Care Insurance, you may be able to get coverage for chronic care. We’re here to help you learn what long term care insurance is and what to do if you have LTCI.

CCM for Multiple Conditions

It’s not uncommon for aging adults to face two, three, or more chronic medical conditions. In these cases involving multiple specialists and treatment approaches, chronic care plans are typically more extensive. Care for multiple conditions can be complex, and coordinating it can be a big task.

With that said, Alliance Homecare can work with you on a customized program that aligns with your unique needs, goals, and personal preferences. Additionally, while many people assume chronic care management must take place at a medical facility, our LHCSA makes it possible to receive the care you need right at home.

What to Expect from At-Home Chronic Care Management

In a recent AARP survey, 80% of folks aged 50 or older want to keep living in their homes for as long as possible. Though chronic health problems can make it more difficult to maintain this independence, at-home care can be a great solution.

The CCM services we provide at Alliance Homecare include care from skilled registered nurses who specialize in various illnesses and health conditions. They’ll work closely with your physician and any other healthcare provider to monitor your progress and ensure you’re receiving the proper support.

Additionally, for those struggling to make it to the bathroom in time, take medications as prescribed, attend appointments outside the home, get in and out of bed, prepare and eat food, or maintain good hygiene, a home health aides can step in. Our caregivers at Alliance have the training and experience to address various health and functional issues caused by chronic disease.

Patients will have a way to contact someone from their care team 24 hours a day, seven days a week. This means urgent needs and emergencies will always be addressed in a timely manner.

Alliance Homecare is committed to providing patient-centered care. This means your chronic care management plan will be tailored to your condition, needs, values, and goals. Not only that but each plan is continually evaluated to ensure the treatments and services are in the best interest of the patient for the long term.

At-Home Chronic Care Management in New York

Chronic illness can be devastating to individuals and their families. In the face of ongoing pain, discomfort, and uncertainty, many want nothing more than to remain in the comfort of their homes. Alliance Homecare makes this possible by offering comprehensive chronic disease management services to patients in the New York metro area.

Our compassionate care plans are designed to improve patient outcomes with severe illnesses, including Alzheimer’s disease, cancer, Parkinson’s disease, diabetes, stroke, multiple Sclerosis (MS), ALS, and heart disease, and more. The team at Alliance can help you and your loved ones go over your options and navigate the challenges of living with a chronic health condition.

Contact us Alliance Homecare for more information about private nursing care and home health aide services.

 

External sources:

  1. https://aspe.hhs.gov/basic-report/what-lifetime-risk-needing-and-receiving-long-term-services-and-supports
  2. https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/chronic-care-management
  3. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf
  4. https://www.aarp.org/research/topics/community/info-2018/2018-home-community-preference.html
  5. https://www.cdc.gov/chronicdisease/index.htm
  6. https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/chronic-care-management.html
  7. https://www.medicare.gov/coverage/chronic-care-management-services

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