Building Blocks of Primary Care, Part 2: Better Between-Visit Care with Chronic Care Management


By John Findley, MD, Caravan Health Medical Director, ACO Programs

The Chronic Disease Conundrum

The challenge of managing Medicare patients with multiple health conditions is familiar to most providers. According to recent data from the Centers for Medicare and Medicaid Services (CMS), two-thirds of Medicare patients have two or more chronic conditions. Establishing treatment guidelines for every condition and for every patient is challenging for a multitude of reasons. A recent study estimated that 37 percent of the average family physician’s time is spent on chronic care, with the balance on acute or preventive care. For Medicare patients, it may be even higher.

Much of this time spent managing chronic disease is consumed with repeated efforts to educate the patient on the importance of lifestyle modifications, self-care, and adherence to treatment plans — activities that trained non-physicians could perform equally well. This blog post explores how medical practices can use care coordination to improve the quality of care for patients and reduce the workload of the primary care physician.

Better Between-Visit Care

Every physician has seen it—a patient with chronic illnesses comes in for a regular appointment and it’s clear that the patient has not been able to keep up with managing medications, at-home treatments, or other basic preventive self-care. One highly effective strategy to address this issue is active outreach to patients between visits with their doctor. However, this outreach is highly time-consuming.

In 2015, CMS established Chronic Care Management (CCM) services as a team-based solution to this problem. These services are a critical component of accountable care organizations (ACOs) and other value-based efforts, providing a between-visit connection to the doctor’s office that helps patient stay current with all aspects of their treatment plan. In addition to ongoing nursing support, CCM can provide access to social support, counseling, and other community resources that can improve treatment compliance and quality of life.

The impact on patient outcomes is real. CCM helps health professionals better manage the complexities associated with patients who have multiple co-morbidities, thus avoiding acute exacerbations that result in more costly interventions. A recent Health Affairs evaluation of Medicare beneficiaries determined that better management of three highly prevalent chronic diseases — hypertension, diabetes, and hyperlipidemia — resulted in a 56 percent reduction in hospital admissions for acute ischemic heart disease and a 41 percent reduction in admissions for stroke. Better chronic disease management matters to patients, to providers, and to payers. 

Care Management Improves Physician Well-Being

In order to provide the best care for patients with multiple serious conditions, we must look at how physicians are spending their time. Increased requirements for documentation, coding, and quality reporting are placing new demands on providers already taxed for time. Modern medicine has built a system in which less than a third of a physician’s average day is spent in face-to-face time with patients, and half is consumed in electronic health record (EHR) documentation and desk work. All of this non-clinical work has consequences. A 2003 study tells us that only “approximately half of eligible patients receive recommended preventive, chronic disease, and acute care services.”

Many of these administrative tasks can and should be performed by support staff under the supervision of the billing provider. A model such as CCM, which delegates some of this work to non-physicians, frees up time for physicians to spend more quality face-to-face time with patients, focus on critical acute conditions, and provide ongoing oversight and supervision to ensure that established care plans are delivered effectively. By design, physicians can put a nurse at the helm of CCM programs, decreasing some unnecessary burdens and, therefore, serving more patients.

Better ACO Financial Performance

A recent independently commissioned evaluation of Medicare demonstration projects revealed that robust CCM programs have reduced total Medicare expenditures by 3-6 percent, with reductions driven primarily by decreased hospital admissions and emergency department (ED) visits. These CCM services reduced total Medicare expenditures by $74 per beneficiary per month over an 18-month period. Caravan Health partners that establish CCM as part of their standard work have consistently seen comparable improvements. 

Chronic Care Management – Experience of a Caravan Health Partner Practice

Much like our work with annual wellness visits, Caravan Health has found that CCM improves care for patients and helps providers get their critical work done in the most efficient and effective way. In our experience, CCM has a measurable effect on both the health of chronically ill patients and the productivity of the health care practitioners.

We spoke with Kristylee Castorena, a registered nurse (RN) at the Haleiwa Family Health Center on the North Shore of Oahu in Hawaii. The Haleiwa Family Health Center participates in the Comprehensive Primary Care Plus (CPC+) program, a CMS payment model aimed at enhancing primary care through practice transformation.

Ms. Castorena runs the Chronic Care Management program at Haleiwa, which has about 50 active patients, many of whom have uncontrolled diabetes. She says, “With a case of uncontrolled diabetes, you just can’t wait and see the patient every three months since there is the risk of so many complications. It could be as serious as permanent blindness or serious kidney or nerve issues.”

“We have found it helpful to get tests done about every three to four weeks. That gives us a chance to get a read on the average blood sugar and start a new medication and figure out if it’s working or if the patient needs new treatments or lifestyle modifications before the next appointment.”

Ms. Castorena continues, “The practice doctors have really come to rely on me and the CCM services anytime a patient’s blood sugar is measuring high and it’s not clear the patient can manage treatment on their own. One benefit is that, while doctors only have a 15-minute visit to address all the chronic care problems, I can take a little more time to make sure there are no obstacles to getting treatment.”

“It’s great when a doctor can refer a patient to me for either a face-to-face or telephone meeting. I have the time to get to know the patient’s specific diagnoses, treatments, and living situation. This support makes it possible to get a better blood sugar measurement and feel better overall. Some patients need a whole lot of extra support and I even have a handful that I try to call every single day. That could continue until they feel confident enough to manage their own treatment, which is the goal.”

“When I started as Chronic Care Manager in 2017, 25 percent of our patients had uncontrolled diabetes. Our most recent numbers showed that rate is down to 9 percent. This care management work is paying off.”

Looking Ahead

Our ability to effectively treat the growing number of individuals who live with multiple chronic diseases will remain compromised unless health systems explore innovative approaches. Chronic Care Management programs are a viable solution for exceedingly busy practitioners. There is great news on the horizon as CMS continues to enhance the services available. There are plans to increase the CCM codes to allow for more incremental coding; to increase payment for Transitional Care Management to ease the move home from a hospital stay; and, for the first time, to allow providers to bill for Principal Care Management for beneficiaries with a single serious chronic condition.

These new policy changes show that CMS understands the value of care management in both keeping patients healthy and keeping medical practices running optimally. We anticipate that the menu of available team-based solutions will grow in the coming years.