Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month, with the following required elements:
CPT4 code
Name of the Procedure:
Chronic Care Management (CCM) Services
Common names: Chronic Care Management, Ongoing Care, Long-Term Care Coordination
Summary
Chronic Care Management services are designed to provide a continuous care plan for patients with multiple chronic conditions. These services involve a physician or qualified health care professional dedicating at least 30 minutes per month to manage and coordinate a patient's health care.
Purpose
Chronic Care Management aims to improve the quality of life for individuals with long-term health conditions. The procedure endeavors to reduce hospital admissions, manage symptoms effectively, and prevent the worsening of chronic diseases.
Indications
- Patients with two or more chronic conditions (e.g., diabetes, hypertension, arthritis, COPD, etc.).
- Those needing regular monitoring, adjustments in treatment, and continuous health education.
- Criteria: Patients must have significant risk of death, acute exacerbation, or functional decline.
Preparation
- There are no specific pre-procedure instructions for patients.
- An initial comprehensive health assessment is done to create a personalized care plan.
Procedure Description
- Initial Assessment: Comprehensive evaluation of medical history, current health conditions, medications, and lifestyle.
- Care Plan Development: Creation of a detailed care plan addressing all chronic conditions, including goals, treatments, and follow-up schedules.
- Monthly Coordination: At least 30 minutes each month dedicated to patient care tasks such as reviewing progress, updating the care plan, coordinating with specialists, and providing health education.
- Use of Technology: Secure communication tools and electronic health records to facilitate ongoing monitoring and adjustments.
Duration
The chronic care management process spans the entire month, with a minimum of 30 minutes allocated to direct patient care and coordination tasks.
Setting
Chronic Care Management services can be provided in various settings, including outpatient clinics, physician’s offices, and remotely through telehealth services.
Personnel
- Primary Care Physician (PCP) or a qualified health care professional.
- Support staff such as nurses, medical assistants, and care coordinators.
Risks and Complications
- Risks are minimal but may include miscommunication or delays in care coordination.
- Complications can arise if the patient's condition worsens due to ineffective management or noncompliance with the care plan.
Benefits
- Improved management of chronic conditions.
- Reduced hospital admissions and emergency visits.
- Enhanced quality of life and patient satisfaction.
- Benefits can often be seen within the first few months of consistent care management.
Recovery
- No recovery period as it is an ongoing service.
- Patients receive continuous support and adjustments to their care plan based on regular assessments.
Alternatives
- Sporadic care without a structured plan.
- Episodic care focused only on acute issues.
- Pros: Less time-intensive for patients.
- Cons: Potentially higher risks of complications and hospitalizations due to lack of continuous care and monitoring.
Patient Experience
- Patients generally experience improved coordination of care, better health outcomes, and potentially fewer crises or hospital visits.
- Pain management and comfort measures are integrated into the care plan as needed.
- Regular communication and follow-ups are essential to ensure patient comfort and adherence to the care plan.