Name of the Procedure:

Chronic Care Management (CCM) Services
Common name(s): CCM Services, Chronic Care
Technical term: HCPCS Code G2058

Summary

Chronic Care Management services involve additional clinical staff time directed by a physician or other qualified health care professional to help manage chronic conditions. This service supports primary care by offering ongoing management for patients with multiple chronic conditions, improving their health outcomes and quality of life.

Purpose

CCM services address the ongoing needs of patients with multiple chronic conditions. The goal is to improve the health of these patients by providing consistent, comprehensive care management to prevent complications, reduce hospitalizations, and support better health outcomes.

Indications

• Patients with two or more chronic conditions expected to last at least 12 months or until the patient’s death.
• Conditions that place the patient at significant risk of death, acute exacerbation, or functional decline.
• The patient must agree to receive CCM services to be eligible.

Preparation

• Patients should provide a complete medical history and list of current medications.
• No specific pre-procedure instructions such as fasting; however, a review of the patient’s condition and needs is crucial.
• Relevant diagnostic tests or assessments might be reviewed or performed as needed.

Procedure Description

1. Initial Assessment: Healthcare provider reviews the patient’s medical history and current health status.
2. Care Planning: A comprehensive, individual care plan is developed outlining treatment goals and strategies.
3. Coordination of Care: Involves coordinating specialist care, prescriptions, and other health services.
4. Monitoring and Follow-Up: Regular check-ins by clinical staff to monitor health status, adherence to the care plan, and any new symptoms or problems.
5. Documentation: Clinical staff document their time and activities.

Tools and equipment: Clinical software for patient management, communication devices.

Anesthesia or sedation details: Not applicable.

Duration

Each additional 20 minutes of clinical staff time is tracked per calendar month, aside from the primary procedure.

Setting

CCM services are typically performed in outpatient settings, such as primary care offices or clinics, but can also be managed remotely through telehealth services.

Personnel

• Physicians
• Qualified health care professionals (e.g., nurse practitioners, physician assistants)
• Clinical staff (registered nurses, care coordinators)

Risks and Complications

The risks associated with CCM are minimal but may include:

• Miscommunication among care team members leading to care discrepancies.
• Administrative errors in managing care plans.

Benefits

• Improved management of chronic conditions.
• Reduced hospitalizations and emergency room visits.
• Enhanced patient engagement and adherence to treatment plans.
• Better overall health outcomes.

Recovery

There is no traditional recovery period as CCM is an ongoing service. Patients should adhere to care plans and attend follow-up appointments as outlined.

Alternatives

• Standard primary care visits without additional CCM services.
• Specialist care for individual conditions without integrated management. Pros and Cons:
• Alternatives may result in less coordinated care, which can lead to increased hospitalizations and poorer health outcomes.

Patient Experience

During the procedure, patients can expect regular check-ins by clinical staff, either in-person or via telemedicine. They might experience an enhanced understanding of their health conditions, better medication management, and improved healthcare support. Comfort measures include easy access to the healthcare team for concerns and questions, fostering a supportive environment for ongoing care management.