What is included in chronic care management?

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.

What is the care management process?

Care Management means a set of Enrollee-centered, goal-oriented, culturally relevant and logical steps to assure that an Enrollee receives needed services in a supportive, effective, efficient, timely and cost-effective manner.

What are the core elements of chronic disease management?

The Chronic Care Model includes six essential elements of a health care system that when integrated encourage high-quality chronic disease care:

• Community resources.
• Health system.
• Self-management support.
• Delivery system design.
• Decision support.
• Clinical information systems.

What does a chronic care management nurse do?

CCM includes structured recording of patient health information, maintaining a comprehensive electronic care plan month to month, managing transitions of care and other care management services, and coordinating and sharing patient health information timely within and outside the facility and practice.

What are the key elements of a care management plan?

Six Key Elements of Care Management Success

• Patient Advocacy.
• Cultural Competence and Social Determinant Awareness.
• Leadership Support.
• Communication Skills.
• Data-Informed Patient Prioritization.
• The Human Element.

What are examples of management of care?

Components of care management include:

• Patient education.
• Medication management and adherence support.
• Risk stratification.
• Population management.
• Coordination of care transitions.
• Care planning.

What do you need to know about chronic care management?

– ‘Round-the-Clock access to Care management Services. – Care Continuity. – Care Management. – A Patient-Centered Care Plan. – Help with Care Transitions. – Care coordination with Home and Community-based Providers. – Enhanced Communication. – Electronic Record and Availability of Care Plan.

Who can provide chronic care management?

Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more), significant chronic conditions. Other licensed clinical staff can provide services “incident to” the primary clinician, as long as the primary provide is providing general supervision.

How is chronic care management defined?

– Incentivize CM services through CMS transitional CM and chronic care coordination billing codes – Provide variety of financial and non-financial supports to develop, implement and sustain CM – Reward CM programs that achieve the triple aim

What are the requirements for chronic care management?

outside of the practice and other care management services. CMS requires that the CCM Care Plan include, at a minimum, the following elements: • Complete problem list • Expected outcome and prognosis • Measurable treatment goals • Symptom management • Planned interventions and identification of the