Chronic care management is exactly what it sounds like: the activities and oversights of healthcare professionals, to help patients with chronic conditions. But, of course, there’s more to it than that.
Definition of Chronic Care Management
In a general sense, chronic care management encompasses any care provided by healthcare professionals to patients with chronic diseases and health conditions, such as fibromyalgia, diabetes, multiple sclerosis, lupus, and high blood pressure.
The primary goal is to help patients, via therapies and interventions, to live with less pain related to their chronic conditions – to achieve a better quality of life through ongoing care and management of their conditions.
More specifically, in the United States, Chronic Care Management (CCM) often refers to the face-to-face services provided to Medicare and Medicaid beneficiaries with more than one significant chronic condition.
In Medicare and Medicaid terms, CCM relies on not only face-to-face care but also refers to any communications and coordination of care related to chronic pain and medication management.
Goals of Chronic Care Management
Medical professionals cannot apply a one-size-fits-all approach to the goals of chronic pain management; they depend on the patient and the illness.
That said, the overarching goal of chronic pain management is an improved quality of life. This may extend to:
- Reduced pain
- Increased mobility
- Better sleep
- Reduced stress Increased physical condition (flexibility, endurance, strength, etc.)
- Return to previous activities, hobbies, work, etc.,
Challenges of Chronic Care Management
Chronic pain management has been disjointed, with poor coordination between providers, treatments, and the settings of chronic illness care. Add to this the complicated nature of chronic pain and illness, and patients have had difficulty complying with the protocols and coordination that do exist.
It’s more than that, though: Due to the complicated nature of chronic illnesses, their care and management require longer, more frequent, and more in-depth medical visits than does, for example, acute care. Additionally, due to the nature of chronic illnesses, a given treatment may be more or less effective, depending on the stage of a chronic illness.
Furthermore, fragmentation of care is common, in part because chronic conditions often coexist. In this case, patients may see one specialist for one chronic condition, and another specialist for a different condition.
Often, these specialists cannot or simply do not work together, even though the patient would benefit from careful coordination of care. That said, significant advances in CCM have been made in recent years.
The Evolution of Chronic Care Management
As far as a medical timeline, chronic care management is a relatively new branch of medicine. It wasn’t until the 1980s and 1990s – and the work of nurse researchers, including C. Baker, C. S. Burckhardt, and Sally Wellard – that the medical community began to truly understand the phases and stages of chronic care and their related interventions, which work differently during different stages of a chronic illness.
In 2004, Patricia Fennel published the Fennell Four Phase Model of chronic illness. This stood as an important development in the understanding of chronic illness and its management. According to the model, patients pass through four phases – Crisis, Stabilization, Integration, and Resolution – as they learn to incorporate changes and therapies into their lives, and adapt to the lifestyle changes associated with their conditions.
Over the last two decades, chronic pain care and management have seen significant strides toward the development of treatments and understanding of the physical and psychological effects that chronic illness has on patients.
Let us know what you think of CMS’s initiative on chronic care management.
Read a detailed outlook from CMS on CCM services.
If you enjoyed this post, help it spread by emailing it to a friend, or sharing it on Twitter or Facebook. Thank you!