Chronic care management (CCM) is at the core of the Triple Aim, a key population health approach. The Triple Aim Initiative is a framework targeted at optimizing health systems and practices. The three dimensions of Triple Aim are “to improve the patient experience of care (including quality and satisfaction), improve population health, and reduce costs per capita.”
Active patient engagement which elevates the patient experience, improves care outcomes and Quality of Life (QALY). Keeping in mind that the best practices and health systems not only meet the metrics of standards, but also lift the spirits of patients. Coordinated care, transitional care, and even tele-health can all play key roles in elevating a practice and health system's population health strategy. Perhaps most importantly consistent patient engagement enhances patient safety, quality and satisfaction.
Nearly 1 out of 3 people in the U.S. population has at least one chronic disease, such as chronic obstructive pulmonary disease (COPD), diabetes, heart disease or hypertension. Costs in general for managing chronic diseases can be overwhelming as 86 cents of every healthcare dollar goes to treatment of chronic diseases.^ For most providers, managing chronic diseases and patients with compounding medical and psychosocial needs can be overwhelming.
Practices and clinicians recognize the challenges of coordinating care for these complex conditions, as well as the importance of staying connected to their patients for better quality of care.
As part of its Road Forward strategy, the Centers for Medicare and Medicaid (CMS) launched the Chronic Care Management (CCM) program to reimburse for non-face-to-face care coordination services. CMS also initiated a Transitional Care Management (TCM) program for services provided to patients whose physical and mental health conditions require moderate or more difficult medical decision making. TCM eligible patients would require more attention within 1 to 2 weeks following transition from an acute care/inpatient setting to a more observational environment such as a skilled nursing facility, assisted living, or in some instances the patient’s home, for example. Understanding how these programs impact the bottom-line is important for successful implementation.
May is National Stroke Awareness Month. Every 40 seconds, someone has a stroke, and every 4 minutes someone dies from this, a leading cause of death and disability in the United States. Strokes often lead to serious, life-changing complications that may include paralysis or weakness on one side of the body, problems comprehending or forming speech, and even depression. Patients with multiple (two or more) chronic conditions like high blood pressure, atrial fibrillation (AFib), and diabetes, for example, are at particular risk. Enrolling patients in chronic care management and having a comprehensive care plan can help clinicians be more aware of patient risks before any acute episode or functional decline.
Symptoms may include dizziness, or loss of balance, numbness or weakness of the face, arm, or leg, or difficulty speaking. One way to look out for stroke symptoms is to remember F.A.S.T.
- Face - Uneven smile
- Arm - Arm weakness or numbness
- Speech - Slurred speech or difficulty talking
- Time - You have to act quickly — call 911 immediately