Chronic care management includes any care provided by medical professionals to patients who have chronic diseases and conditions. A disease or condition is chronic when it lasts a year or more, requires ongoing medical attention, or limits the activities of daily life. It includes physical conditions like diabetes, arthritis, and hypertension or mental conditions like dementia or depression. Services include not only in person, face-to-face visits but also communication and the coordination of care related to the chronic conditions that a patient faces.
Goals of Chronic Care Management
People with multiple chronic conditions are at an increased risk for poor quality of life. The overarching goal of chronic care management is to help patients achieve a better quality of life through continuous care and management of their conditions. In a chronic care management program, a patient might have reduced pain and stress, increased mobility and physical fitness, and better sleep and relaxation. A goal of the healthcare system in chronic care management is to support patient self-care. CCM places more emphasis on individual behavior and a person’s responsibility in managing their health more effectively and independently. Patients with chronic conditions play an essential role in monitoring their health and any changes in it.
CCM Services Help to Decrease Healthcare Fragmentation
As the number of chronic conditions increases in a person, the risk of mortality, hospitalization, and medication interactions increases with multiple chronic conditions directly contributing to disability, confusion, and poor quality of life. Patients with multiple chronic conditions usually require more extended, more in-depth, and more frequent provider visits than is typical for other patients. The level of complexity of a patient with multiple chronic conditions requires a higher level of coordination amongst medical professionals in order to avoid the fragmentation of care that otherwise may occur. Patients with multiple chronic conditions have a higher chance of receiving conflicting advice from their many health care providers unless they are all on the same page. Frequently, treatments for chronic conditions and diseases are complicated, making it difficult for patients and their caregiver support systems to comply with the treatment protocols, or sometimes even to understand them.
While other housecall companies employ medical assistants working off of pre-built scripts to run their chronic care management programs, at HomeMD Housecall Services we are committed to providing the highest quality of care possible, which that while we have plenty of wonderful medical assistants employed in our office, we only use registered nurses to run this program. Our team of RNs will spend quality time intmittently throughout every month on the phone or over our tablets to virtually check up on and “hold the hands” of our patients and their support systems in such a way that they can be patiently guided through what is otherwise a complicated, fragmented, and more often than not broken healthcare system. While connecting with the patients they are case managing through our CCM program, our registered nurses will use their extensive medical experiences to spot for volatility that could indicate a medical problem. For instance, while calling to provide Mrs. Smith with some information regarding her new hypertension diagnosis, she will also be checking in to ensure that she is feeling OK. Part of checking in is triaging the patient for any subtle changes that might raise red flags for our provider staff to follow up on. Perhaps Mrs. Smith, who is ordinarily very sharp, can’t remember the name of her cat today or she mentions in conversation that she fell down the other day. The circumstances of the phone call could then be communicated to her provider as well as to her daughter by the nurse case manager. The provider could then setup an onsite visit, a same day telephonic visit, or perhaps just a phone call to assess the situation for herself
Empowering patients with quick & easy access to care
More so than any other population, geriatric patients are at risk of chronic conditions turning into acute conditions very quickly. In addition to providing a robust portfolio of in-home medical care services (see table to the right) to complement our primary care services, we find access to care to be critically important to this population, which is why we have gone to great lengths to provide it. During the patient intake process, every patient at HomeMD Housecall Services is offered a cellular connected tablet paid for at our expense to enable instant access to care. We understand that sometimes new technology is difficult for seniors to handle, therefore we have manipulated the software in our tablets in such a way that our tablets are simple to use, even for geriatics . . . simply put, if they can hold it than they can use it. Beyond empowering our patients and their family members with instant access to medical care by their provider team, patient families are also able to utilize our tablets to connect to patients outside of their medical needs
A couple of scenarios to consider: :
Lets meet Mrs. Smith, an ordinarily very sharp and witty 88 year old female who has a HomeMD Housecall Services provider visiting her in her home on a monthly basis for the management of her primary care, which includes the management of type 2 diabetes and new onset hypertension. While her diabetes is doing great as shown by the remote monitoring glucometer readings in our chart, her blood pressure has been a bit elevated over the last couple of months. She was put on a new medication last month for the blood pressure issue and today she gets a phone call from our chronic care management registered nurse to communicate to her that as good fortune would have it, the remotely connected blood pressure device we have given her to use is reporting very good news regarding her vital signs. Unfortunately, the nurse notes that Mrs. Smith seems to be having a bit of difficulty remembering the name of her cat today. The next phone call is to the patient’s daughter who notes that she too was wondering how mom was doing today because over the last few days she’s “seemed a little off”. In fact, the daughter reports that Mrs. Smith almost fell down a couple of days ago. The nurse immediately reports this to the patient’s HomeMD Housecall Services primary care provider who intitiates a telephonic visit with Mrs. Smith through the cellullar connected tablet that we have given to her. During this encounter, the patient looks disheveled (not like Mrs. Smith) and she reports that she is urinating quite a lot lately. From there, our provider sends off an order to our mobile lab partner who collects a urine sample along with some bloodwork the following morning. Results are had by mid-day, indicating that Mrs. Smith will need an antibiotic for a urinary tract infection, which seems to be the likely cause of all of her current problems. After contacting the daughter to update her on what our diagnosis and treatment plan is, we call the antibiotic into a delivery pharmacy who gets the medication to the patient later that afternoon. Within a day or two the patient is doing much better and continues to recover well as noted during both of the follow phone calls our chronic care management RN makes to the patient as well as the one made to her daughter, both of which occurred during the following week.
Mr. Jones, an elderly man living in one of the assisted living facilities that we service for primary care, is being contacted by our CCM registered nurse case manager to follow up with the facility’s nurse on a condition that was treated a few days ago. During the conversation it is noted to our nurse that as per the report from the mobile X-ray completed this morning, the antibiotic we ordered for Mr. Jones’ pneumonia is clearing everything up quite nicely, much to the pleasure of our primary care NP who has been providing his medical care for the last 3 years. The facility nurse mentions to our case manager that while he is certainly less short of breath today consequent the medication, he is still quite weak . . . both presume that he might be a bit weaker for some time while recovering from pneumonia and that a physical therapy referral may be helpful. After the phone call our case manager contacts the patient’s HomeMD primary care provider to relay her suggestions. The provider thanks the nurse for the useful information and promptly requests of her medical assistant that she send a referral off to one of our many skilled home healthcare partner companies for physical therapy; the patient requests the same one she has seen for multiple other issues in the past, a request for which we are happy to oblige. Two days after the referral is sent, our referral follow up team contacts the skilled home health company to make sure that the referral has been processed, that the patient has been scheduled for their visit, and to make sure that they noted the order paired with the physical therapy referral indicating that our provider would like a home health aid to assist the patient with his showering a couple of times per week for the next few weeks, just until their therapy has made him strong enough to resume doing it safely on his own. The homecare office person notes that the evaluation visit was completed this morning and that their therapist would be calling to give our team a verbal report in a matter of hours. Our nurse case manager, involved in the whole process from the beginning to the end, reaches back out to the facility manager to update her on the status of her resident, which is followed by a phone call to the patient’s son who lives in Arizona.
To be clear, although the level of care described in the scenarios above seems to be quite extraordinary, this is in fact how medical care is provided every single day at HomeMD Housecall Services . . . as an organization we would accept nothing less. Our office is filled with some of the most wonderful, caring, and compassionate clinicians and office staff who all take a great deal of pride in providing the highest level of care to our patients and it is our commitment to clinical substance through the development of effective communication systems that sets them free to do what they do best . . . making our patients feel better and their families feel both informed and supported!