Chronic Care Management

An estimated 117 million adults have at least one chronic health condition, and an estimated one in every four adults have two or more chronic health conditions. In a questionable healthcare system, mostly focused on treatment instead of prevention, it is not a wonder. Medical providers actually profit short-term by sick patients visiting often. But, frankly, medical providers are also strained with high-demand patient loads, and time and resources do not allow easy tracking. So care has not been very outcomes based – communication post treatment, assessment of disease reversal, etc.

The Centers for Medicare and Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. Since 2015, Medicare has been reimbursing medical providers for CCM services. Eligible patients are those with two or more chronic conditions expected to last at least 12 months or until death, and that place the patient at significant risk of death, acute decompensation or functional decline.

Examples of chronic conditions include, but are not limited to:

  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Cancer
  • Cardiovascular Disease
  • Chronic Obstructive Pulmonary Disease
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases such as HIV/AIDS

Wow! Now that I’ve caught you up on the background…

I had the pleasure of helping Doctor for Life launch their Chronic Care Management program, enabling us to create individualized, comprehensive care plans including special education, motivation and follow-up efforts to better patient health outcomes. Medicare covered non face-to-face encounters such as the following, with patients only responsible for a small monthly co-pay:

  • At least 20 minutes per month of chronic care management services
  • Personalized help from a health care professional to create a care plan based on your needs and goals
  • Care coordinated between your doctor, pharmacy, specialists, testing centers, hospitals, and other services
  • Phone check-ins between visits to keep you on track
  • Emergency access to a health care professional, 24 hours a day, 7 days a week
  • Expert help with setting and meeting your health goals
  • Review of medical records and test results
  • Medication refills and management
  • Scheduling same-day appointments

Doctor for Life also decided to offer free group education classes each month – one in Fitness and one in Nutrition. (Yes, you guessed it, I was leading the classes on Fitness. 😉 ) My lessons included:

  • Exercise for the Prevention of Falls / Balance Testing
  • Exercise for Independence / Activities of Daily Living
  • Habits to Improve Health / Lifestyle & Techniques

Participants definitely learned and laughed. (I mean, making them laugh is like my number one goal.) I enjoyed the process too, getting to dig deeper into the perspective of others. I do not have a chronic disease, but I need to understand as much as possible about what that’s like in order to help people.

Health pros must be knowledgeable and empathize. I’m grateful for this opportunity at DFL, and feel the need to share with everyone what some medical providers are doing to improve care and, working together, get patients to their desired health goals.

The outcomes really are positively improving. Recent statistics show that it is worth CMS paying providers because they are saving by lowering benefit payouts to individuals, meaning patients’ care is being routinely controlled instead of having more emergency and extra inpatient or outpatient needs.

If you or someone you know is interested and eligible, please ask your providers accepting Medicare about this level of concierge care.


CMS website >

CMS handout >

Medicare website >

Modern Healthcare article >

Published by Aarika

Personally... I am a writer and perpetual student. Professionally... I specialize in Wellness Coaching and Communications and aim to help people seek, find and maintain health. <3

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