Chronic Care Management

What Is Chronic Care Management?

As a patient with many medical needs, you already spend a good deal of face-to-face time with your healthcare providers. Did you know that your doctors and nurses may think about your healthcare needs even when you’re not with them?

CCM helps your medical team to work behind-the-scenes on your behalf. This program allows them to set aside time just for your needs. The person in charge of your case can use this time to assist you with appointments, look over your medications and ensure refills are available in a timely manner, review your care plan, reach out to the members of your medical team if a problem arises and talk to you about your health needs.

You aren’t automatically enrolled in CCM. If you qualify for this service, your healthcare provider may discuss the option with you. Then, you’ll need to sign a form or provide verbal consent indicating that you want to begin receiving CCM services.

How to Qualify for CCM

Chronic care management is reserved for select patients. Before enrolling in this program, you will need to meet all of the qualifications.

To benefit from CCM services at LISH, you must:

• Be a Medicare recipient or have Medicaid and Medicare combined
• Have two or more chronic conditions
• Be a LISH patient who sees at least one primary care provider or specialist at our clinics

If you meet all of the above qualifications, you can inquire about your eligibility for the CCM program.

Common Chronic Conditions

One of the main requirements for CCM is that you must have at least two chronic conditions. Chronic healthcare needs are long-term ones. More specifically, they are expected to affect you for at least one full year. They might even be conditions that you’ll deal with for the rest of your life.

Examples of chronic conditions include:

• Arthritis
• Asthma
• Autism spectrum disorders
• Cancer
• Chronic Obstructive Pulmonary Disease
• Depression
• Dementia
• Diabetes
• Heart disease
• Infectious diseases
• Hypertension
• Lupus
• Mental health disorders
• Multiple sclerosis
• Osteoporosis

This is not an exhaustive list. Your doctor may identify other chronic conditions that could make you eligible to receive CCM services.

For CCM eligibility, your chronic conditions must negatively impact your life. For example, they might be conditions that increase your risk of death or reduce your ability to carry out everyday tasks. They may also be conditions that can suddenly worsen and cause acute symptoms.

Your Customized CCM Plan

When you enroll in CCM, you will receive a personalized care plan. This plan will include details about you and your medical care.

It will include information such as:

• Healthcare providers
• Medical diagnoses
• Medications
• Supportive services

In addition to providers and services from the health center that maintains your CCM plan, this list may also include care options from other medical centers and community agencies.

Your CCM healthcare plan will also include treatment goals. These will be personalized for your unique situation, but they may include ideas such as:

• Achieving greater flexibility
• Being able to engage in hobbies or other favorite activities
• Being able to hold down a job
• Experiencing fewer symptoms
• Gaining increased independence
• Getting better sleep
• Having flare ups less frequently
• Lowering your stress level
• Reducing your daily pain level

Because chronic conditions don’t always have a cure, your goals may focus on symptom management and improved functioning rather than complete healing.

The medical staff will share your care plan with you. In fact, you’ll receive full access to the information so that you can refer to it at any time.

When something changes with your healthcare needs, your plan can be updated. Your CCM coordinator can oversee transitions and adjustment periods to make sure that everything is running smoothly.

Additional Benefits of CCM

Enrolling in a CCM program also ensures that you’ll have regular access to your medical providers.

The requirements for CCM programs say that patients need to be able to see the same healthcare provider regularly. For routine appointments, you’ll typically visit the same doctor which helps establish the care that is right for you. Although you may still need to see specialists, your services will be coordinated by one central provider.

Being in a CCM program also means that you will be able to reach someone around the clock. Whether it’s a workday, the middle of the night or the weekend, you’ll have an option for getting a hold of a representative from your care team. This person can answer questions about your plan or provide advice for urgent concerns.

Telephone calls won’t be your only option for making CCM contacts. You may also have email addresses or an online patient portal that you can use to reach your healthcare providers.

Learn More About CCM at LISH

When you have multiple chronic conditions, navigating medical decisions can be tricky. On your own, coordinating appointments, managing medication interactions and balancing your many healthcare needs might leave you confused and frustrated. Fortunately, a chronic care management coordinator can partner with you to create a plan for your medical care.

To discuss whether you qualify for CCM services, call LISH’s central office at (631) 650-2510. Information is available through our online contact form as well.