Chronic Care Management Programs Research Articles

Using Chronic Care Management Visits to Reduce the Number of Frequent Emergency Department Visits: A Pilot Study.

Background Emergency department (ED) visits are increasing in number and cost and becoming a major way patients are interacting with the healthcare system. Patients who frequently visit the ED are deemed "super-utilizers" who visit for a variety of reasons, including, but not limited to, multiple chronic medical illnesses, homelessness, and substance use disorder, but fail to have an established long-term treatment plan. Methodology We enrolled our hospital's top 50 super-utilizing patients into the Chronic Care Management Program. These patients received monthly telehealth visits to discuss concerns, chronic medical conditions, barriers to care, and support systems unique to each patient's living and social situation (i.e., social determinants of health). Telehealth visits also connected patients to community resources and helped them initiate advanced care services. Results The t-test investigating the frequency of avoidable visits pre- and post-intervention revealed a statistically significant decrease in the number of avoidable visits between the pre-intervention and post-intervention. Results also revealed a non-statistically significant difference in the cost of avoidable visits before and after the intervention. Conclusions The findings revealed a statistically significant decrease in patients' frequency of avoidable visits before and after the intervention.

Evaluation of a Telehealth-Based Pharmacist Led Chronic Care Management Program

Background: Clinical pharmacy services improve several patient chronic disease outcomes. This review evaluates a pharmacist-led chronic care management (CCM) program partnered with a health system for patient outcomes and sustainability. Methods: A mixed methods evaluation based on the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework was completed. Patient A1c and blood pressure readings were retrospectively collected from the electronic health record from August 2018-April 2022. Patients that completed >4 CCM visits with a diagnosis of diabetes and/or hypertension were included. Results: 557 patients enrolled, 53 had uncontrolled systolic blood pressure (SBP), SBP >130 mmHg. Average SBP at baseline was 141.0 mmHg and average SBP at 6 months was 130.2 mmHg, (P < .001). 76 patients had uncontrolled diabetes, A1c > 7%. Average A1c at baseline = 9.1% and average A1c at 6 months = 8.3%, (P < .001). 4464 CCM visits with 247 disease-state targeted patients were completed over 44-month with a 100% adoption rate across clinic locations. Implementation facilitators included patient medication cost concerns, disease burden, provider revenue generation, CCM dedicated software, streamlined call process, and remote EMR access. Implementation barriers included provider discomfort “selling the program,” potential patient costs, unclear need from patient, pharmacists not considered providers, pharmacist cost, multi-platform software, reprioritized stakeholder support, and lack of partner site diversification. Program maintenance showed revenue generation was $5925.31-$8879.89 from August 2021-May 2022 and profitability was $3385.61-$1614.23. Conclusion: This study provides lessons learned, strategies for implementation, and ideas for process efficiencies leading to maintenance of a telehealth pharmacist-led CCM service.

Patient satisfaction with pharmacist-led chronic care management services combined with medication synchronization.

Chronic care management (CCM) improves clinical outcomes, enhances patients' adherence with medical treatments, reduces overall cost, and increases patient satisfaction. However, multiple reports have indicated the underutilization of CCM. Implementation literature has emphasized feasibility and different approaches to providing pharmacist-led CCM. This article examines patient acceptability and provides an innovative implementation approach combining both CCM and medication synchronization (MedSync) services. To introduce CCM services to underserved Medicare beneficiaries at a federally qualified health center, the pharmacy department of a federally qualified health center (FQHC) pilot tested a program whereby pharmacists provided CCM to Medicare beneficiaries enrolled in the MedSync service offered by the FQHC's in-house pharmacies. Both services were provided during the same phone call by the pharmacist. After successful completion of the pilot program, a retrospective chart review and patient satisfaction survey were conducted to enhance the quality of the service. A total of 49 patients were enrolled in the CCM program at the time of data collection. Overall, participants were satisfied with the service. The average number of medications per patient was 13.7. Pharmacists were able to identify an average of 4.8 medication-related problems (MRPs) per patient. Most of the MRPs (62%) were resolved directly by the pharmacists via education, over-the-counter medication adjustments, or interventions under consult agreements. In addition to positive patient satisfaction, pharmacists were able to identify and address a significant number of MRPs when providing CCM.

Financial reimbursement and productivity metrics for pharmacist-led chronic care management services in rural practice settings.

The implementation of chronic care management (CCM) services has often been hindered by issues with reimbursement, raising concerns about sustainability. To date, little if any literature has examined the financial feasibility and sustainability of CCM services in rural practice settings. Assess financial reimbursement and productivity metrics for pharmacist-led CCM services at a rural, medically underserved family medicine clinic. This study retrospectively examined data from the clinic's CCM program from October 2020 through May 2021 and included total clinical encounters, minutes of pharmacist time spent on calls, CCM claims, work relative value units (wRVU), financial reimbursement, and overall personnel costs. Over an 8-month period, 46 patients were enrolled in CCM services. Of the 49 CCM calls placed during this time, 31 (63.3%) were billable, though only 20 (64.5% of billable calls) were ultimately reimbursed. Approximately 37% of pharmacist "time-on-task" was not billable. Compared to the $643 required to cover pharmacist time on CCM calls, $822 of reimbursement was collected. This $179 profit, or 27.8% return-on-investment, is similar to results from more urbanized practices. Furthermore, services were "net productive" in wRVU generation, which may appeal to physician stakeholders interested in such targets. Concerns about profitability and sustainability have prevented more widespread CCM implementation. In the present study, pharmacist-led CCM services achieved a 27.8% return-on-investment. Though rural-based CCM services may never attain significant profit margins, this data suggests they can still be financially self-sustaining and "net productive," all while providing high-quality patient care.

Community Pharmacist and Family Medicine Collaboration for Pre-Visit Planning for Shared Patients Receiving Chronic Care Management Services

Background: Pre-visit planning entails completing necessary tasks prior to clinic appointments. Community pharmacists (CPs) have unique knowledge about patients’ medication use but do not routinely provide drug therapy reviews before clinic visits. Objectives: (1) Create and implement a business partnership between a CP and family medicine clinic (FMC) for CP provision of pre-visit medication reviews, and (2) describe the billing experience for shared patients in the FMC chronic care management (CCM) program. Methods: A prospective 8-month study in one community pharmacy and FMC in Iowa. Eligible patients were enrolled in the clinic CCM program and received their prescriptions at the CP. CPs were granted access to the clinic electronic health record (EHR), performed medication reviews, and recorded drug therapy recommendations (DTRs) in the clinic EHR. FMC physicians reviewed CP DTRs before the patient encounter. Time tracking software in the EHR recorded CP and FMC time performing CCM services. CCM revenue was prorated between parties. FMC physicians completed a survey about their experience. Results: Overall, there were 129 CP reviews performed for 95 patients. These reviews resulted in 169 DTRs and 76% were accepted by the physician. There were 71 CCM claims billed and CCM revenue was $3596 ($1796 FMC, $1800 CP). More than 90% of physicians (N = 11) indicated they reviewed CP DTRs before the patient encounter and agreed they were helpful to their practice. Conclusion: CPs completed pre-visit medication reviews and made accepted medication therapy recommendations. CCM billing provided a mechanism for CPs to receive revenue for their services.

Integration of Transitional Care Management into a Chronic Care Management Program: A Quality Improvement Initiative

Integration of Transitional Care Management into a Chronic Care Management Program: A Quality Improvement Initiative

CONNECTING THE DOTS: CHRONIC CARE MANAGEMENT PROGRAM IMPLEMENTATION IN RURAL PRACTICES

Abstract As the focus of healthcare changes from a “sick” care model to a population health model, primary care and specialty clinic practices have new opportunities supported through Medicare reimbursement. The incorporation of team-based care coordination programs into clinic practices is an important step towards value-based care and achieving the Triple Aim: better health for the population, better care for individuals, and lower costs through improvements. Since 2019, six rural Wyoming primary care practices have completed training to implement and expand care coordination programs. HealthTechS3 provides participating clinics with team-based training in the implementation of the Chronic Care Management Program, Behavioral Health Integration, and other billable care coordination services. To date, 301 patients have enrolled in care coordination services. These practices have generated $350,000 in revenue. Using a consolidated implementation framework as a guide, critical components of successful rural care coordination program implementation are discussed.

Aligning PCPS and Patients with Alzheimer’s Research Efforts: MyAlliance for Cognitive Health

AbstractBackgroundFailure to engage and enroll participants from diverse backgrounds is among the biggest challenges slowing generalizable research efforts to treat and prevent Alzheimer’s disease and related dementias. Pivoting to a ‘service first’ approach for engaging all communities may increase research participation by improving the value proposition.MethodThe University of Kansas Alzheimer’s Disease Research Center is taking a programmatic approach to accelerate participation in research and emphasize reaching under‐represented groups (URG: predominantly African Americans, Latinos, and rural residents in the region). The program is a community and service‐oriented strategy for engaging a diverse population through 1) a PCP Network to improve dementia care through a financially‐sustainable Chronic Care Management program, 2) a Patient Network (MyAlliance Research Registry, derived from patients in the PCP network), and 3) a Community Network of diverse stakeholders delivering robust outreach and education. We hypothesized that the sustaining value of this approach would increase enrollee diversity.ResultTo date, MyAlliance has provided social work support to 71 practices and 1169 unique individuals with dementia and their families. Over 2100 individuals receive our weekly communications, and 4 community organizations have trained more than 80 staff members in dementia‐capable engagement with the community. The result has been that since implementation of MyAlliance, 29% of enrollments (255 of 868) identify as URG, double the URG enrollment prior to implementation (14.5%, 658 of 4551).ConclusionService‐based approaches that emphasize community needs and community access points may increase enrollment and enrich the diversity of the participants.

Evaluating the Efficacy of 3 Recruitment Methods for Enrolling Patients in Chronic Care Management Services: A Pilot Study.

Chronic Care Management (CCM) is a billable service that pharmacists can provide either in person or via telephone in ambulatory clinics or community pharmacies. Pharmacists may use this service to expand current roles in patient care and add billable services to an ambulatory care practice. The number of clinics employing CCM is steadily increasing, and to date, there has been limited information published to aid pharmacists who are considering implementing these services. The purpose of this study is to compare enrollment success in a clinic-based, pharmacist-led CCM service using three recruitment strategies to enroll patients: in person, telephone, and provider referred recruitment. This pilot study examined the success of three recruitment strategies using 94 patients eligible for CCM services in a rural health clinic. The primary outcome was successful enrollment in the CCM program with differences in recruitment strategy enrollment success examined using a Chi-square test. Overall, 42 of 94 patients (45%) were successfully enrolled in the CCM program with no statistical difference appreciated between telephone, in person, and provider referred recruitment. Nearly 33% (14/42) of patients enrolled in person, 40% (17/42) enrolled via telephone, and 26% (11/42) enrolled when referred from a provider. Ten patients (11%) declined enrollment outright. The remaining 42 patients were hesitant to enroll and requested follow up. In conclusion, there was no statistical difference in CCM enrollment success with in person, telephone, or provider referred recruitment, although more patients were enrolled via telephone than with the other two strategies. Pharmacists implementing new CCM programs may tailor their recruitment and enrollment strategy to suit their specific needs.

Participant engagement in a community health worker-delivered intervention and type 2 diabetes clinical outcomes: a quasiexperimental study in MexicanAmericans

ObjectivesThis study helps to fill the existing research gap related to participant engagement in behavioural interventions and diabetes management. We examined type 2 diabetes control over time among Mexican Americans...

Improvement in Clinical Outcomes and Access to Care With Pharmacist-Led Chronic Care Management Services at a Rural Family Medicine Clinic

Background: Chronic care management (CCM) can significantly impact the management of chronic diseases in rural patient populations. To date, few practice models have addressed its impact on clinical outcomes and access to care in rural practice settings. Objective: Implement a sustainable pharmacist-led CCM practice model while tracking clinical outcomes and healthcare access at a rural, medically underserved family medicine clinic. Methods: This study retrospectively examined data from the clinic’s CCM program from October 2020 through May 2021 and included total clinical encounters at three- and 6-months intervals, as well as changes in clinical outcomes like A1c and systolic blood pressure (SBP) at three- and 6-months intervals. Results: Over an 8-month period, 46 patients were enrolled in pharmacist-led CCM services. Those with a CCM encounter or office visit within 3 months of enrollment showed a mean A1c reduction of 1.07% after 3 months (95% CI −1.70 to −.44, P = .0016), while those with an encounter or office visit within 6 months of enrollment displayed a mean A1c reduction of 1.64% after 6 months (95% CI −2.35 to −.92, P < .001). There was a 73.8% increase in total clinical encounters in the 6 months after CCM enrollment compared to the 6 months preceding it, signifying increased access to care. Conclusion: Patients with CCM encounters or office visits within the first 3-6 months experienced statistically significant reductions in A1c. Moreover, total clinical encounters markedly increased in the 6 months after enrollment, allowing for more frequent engagement between ambulatory pharmacists and traditionally challenging rural patients.

Adoption of Patient-Reported Outcomes by Health Systems and Physician Practices in the USA.

Patient-reported outcome measures (PROs) can help clinicians adjust treatments and deliver patient-centered care, but organizational adoption of PROs remains low. This study examines the extent of PRO adoption among health systems and physician practices nationally and examines the organizational capabilities associated with more extensive PRO adoption. Two nationally representative surveys were analyzed in parallel to assess health system and physician practice capabilities associated with adoption of PROs of disability, pain, and depression. A total of 323 US health system and 2,190 physician practice respondents METHODS: Multivariable regression models separately estimated the association of health system and physician practice capabilities associated with system-level and practice-level adoption of PROs. Health system and physician practice adoption of PROs for depression, pain, and disability. Pain (50.6%) and depression (43.8%) PROs were more commonly adopted by all hospitals and medical groups within health systems compared to disability PROs (26.5%). In adjusted analyses, systems with more advanced health IT functions were more likely to use disability (p<0.05) and depression (p<0.01) PROs than systems with less advanced health IT. Practice-level advanced health IT was positively associated with use of depression PRO (p<0.05), but not disability or pain PRO use. Practices with more chronic care management processes, broader medical and social risk screening, and more processes to support patient responsiveness were more likely to adopt each of the three PROs. Compared to independent physician practices, system-owned practices and community health centers were less likely to adopt PROs. Chronic care management programs, routine screening, and patient-centered care initiatives can enable PRO adoption at the practice level. Developing these practice-level capabilities may improve PRO adoption more than solely expanding health IT functions.

P017. Impact of Chronic Care Management on Heart Failure Readmissions

Heart Failure (HF) currently affects 6.2 million Americans, with an expected 8.5 million by 2030. There are 134, 000 annual HF readmissions (CMS) at an estimated cost of $4.5 billion. HF readmission significantly impacts Quality of Life (QOL) and mortality. Research suggests that Chronic Care Management (CCM) programs improve patient outcomes and reduce healthcare costs. Given the significant clinical and economic burdens associated with HF, we examined the effect of Nurse Practitioner led CCM program on hospitalization rate in HF patients. All patients enrolled in the CCM program between May 31, 2017 and January 4, 2019 at the Advanced Heart Disease Clinic were included in the analysis. Criteria for CCM participation included a diagnosis of HF plus another chronic condition. Number of hospitalizations, KCCQ scores, and LVEF scores were collected on each patient during the 18-month period, pre-enrollment and post-enrollment. A non-parametric Wilcox Signed-Rank Test was used to compare hospitalization rate; a Paired Sample T-test was used to compare QOL and LVEF. Twenty-nine patients were included in the analysis. Post CCM enrollment, there was a statistically significant reduction in HF hospitalization compared to pre-enrollment (p= 0.0007; 95% CL). Among the 14 (48%) patients with available KCCQ scores, no statistical difference was found pre to post-enrollment. Among the 25 (86.2%) patients with documented LVEF scores, 48% had improved EFs post enrollment (p=0.20). These results indicated that enrollment in a CCM program for HF may significantly reduce hospitalizations and in turn may have a positive impact on QOL with improvement in LVEF.

Qualitative Analysis of Health Systems Utilizing Non-Face-to-Face Chronic Care Management for Medicare-Insured Patients With Diabetes.

Chronic diseases impact 117 million adults in the United States and account for $3.3 trillion in health care spending. This qualitative study investigated experiences with reimbursement structure for non-face-to-face (NFF) chronic care management (CCM) through diverse health system approaches in primary care settings in Southeastern Louisiana. In-depth interviews were conducted with 16 purposively selected key informants, and reflexive thematic analysis was utilized to explore findings. Variation in health system approaches for implementing and quality of NFF CCM programs were identified. Results included differences in health system motivation and methods for financial structuring and quality of third-party vendor and alternative models.

Applying the Chronic Care Model in a Free Clinic

Uninsured patients with diabetes are less likely than insured patients to receive recommended care and access the appropriate chronic care management programs, resulting in poorer outcomes. A pilot program using the Chronic Care Model framework was implemented to determine its effectiveness in improving clinical and self-management outcomes of high-risk patients with diabetes attending a free clinic for the uninsured. A comparison of baseline and posttest findings showed a statistically significant reduction in hemoglobin A1c. Although not statistically significant, downward trends were observed in blood pressure, triglycerides, and low-density lipoprotein levels. All patients had documented self-management goals and reported high satisfaction with the program. These findings suggest that programs guided by the Chronic Care Model have the potential to improve clinical outcomes and self-management skills of uninsured patients with diabetes.

Exploratory Study of 6-Month Pain Trajectories in Individuals With Predominant Patellofemoral Osteoarthritis: A Cohort Study.

Knowledge of patellofemoral osteoarthritis (OA) pain trajectories is vital to helping clinicians and patients make shared disease-specific decisions regarding treatment options and coping strategies. To describe the pain trajectories of people living with patellofemoral OA who present to a chronic care management program, and to explore baseline characteristics associated with different trajectories. In this prospective longitudinal cohort study, 88 participants who presented to a chronic care management program reported their worst pain over the previous week at baseline and at 6, 12, 18, and 26 weeks using a 10-cm visual analog scale. Trajectories (classes) were identified using latent class growth analysis. Demographics, pain, physical performance, strength, quality of life, mental health, and lower limb/foot structural measures obtained at baseline were assessed for association with trajectory class membership. Individuals in class 1 (28%) exhibited high, persistent pain from baseline (7.8 ± 1.7 cm), which continued over time (P = .52). Class 2 (57%) displayed moderate baseline pain (4.8 ± 1.8 cm), which also remained persistent (P = .97). Individuals in class 3 (15%) showed low, improving pain (baseline pain, 2.6 ± 1.2 cm) over time (P = .017). At baseline, poor Knee injury and Osteoarthritis Outcome Score (KOOS) scores, local and proximal sensitivity to pressure, and lower knee extensor strength were associated with increased odds of following the high-pain trajectory (range [95% confidence interval], 1.03 [1.00, 1.07] to 16.24 [2.53, 104.34]). Distinct pain trajectories appear to exist in people with patellofemoral OA presenting to a chronic care management program. Baseline variables may be useful for identifying individuals at risk of poorer prognosis. Larger studies are needed to confirm the efficacy of this finding. Prognosis, level 2b. J Orthop Sports Phys Ther 2019;49(1):5-16. Epub 12 Sep 2018. doi:10.2519/jospt.2019.8354.

The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations.

In the movement to improve the health of patients with multiple chronic conditions and vulnerabilities, while reducing the need for hospitalizations, care management programs have garnered wide attention and support. The qualitative data presented in this paper sheds new light on key components of successful chronic care management programs. By going beyond a task- and temporal-based framework, this analysis identifies and defines the importance of “authentic healing relationships” in driving individual and systemic change. Drawing on the voices of 30 former clients of the Camden Coalition of Healthcare Providers, the investigators use qualitative methods to identify and elaborate the core elements of the authentic healing relationship—security, genuineness, and continuity—a relationship that is linked to patient motivation and active health management. Although not readily found in the traditional health care delivery system, these authentic healing relationships present significant implications for addressing the persistent health-related needs of patients with frequent hospitalizations. (Population Health Management 2016;19:248–256)

Medicare Chronic Care Management Payments and Financial Returns to Primary Care Practices: A Modeling Study.

Physicians have traditionally been reimbursed for face-to-face visits. A new non-visit-based payment for chronic care management (CCM) of Medicare patients took effect in January 2015. To estimate financial implications of CCM payment for primary care practices. Microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements. National Ambulatory Medical Care Survey and other published sources. Medicare patients. 10 years. Practice-level. Comparison of CCM delivery approaches by staff and physicians. Net revenue per full-time equivalent (FTE) physician; time spent delivering CCM services. If nonphysician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. Practices could expect approximately $332 per enrolled patient per year (95% CI, $234 to $429) if CCM services were delivered by registered nurses (RNs), approximately $372 (CI, $276 to $468) if services were delivered by licensed practical nurses, and approximately $385 (CI, $286 to $485) if services were delivered by medical assistants. For a typical practice, this equates to more than $75 ,00 of net annual revenue per FTE physician and 12 hours of nursing service time per week if 50% of eligible patients enroll. At a minimum, 131 Medicare patients (CI, 115 to 140 patients) must enroll for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services. If physicians were to deliver all CCM services, approximately 25% of practices nationwide could expect net revenue losses due to opportunity costs of face-to-face visit time. The CCM program may alter long-term primary care use, which is difficult to predict. Practices that rely on nonphysician team members to deliver CCM services will probably experience substantial net revenue gains but must enroll a sufficient number of eligible patients to recoup costs. None.

Care Coordination Program For Washington State Medicaid Enrollees Reduced Inpatient Hospital Costs

Managing clinically complex populations poses a major challenge for state agencies trying to control health care costs and improve quality of care for Medicaid beneficiaries. In Washington State a care coordination intervention, the Chronic Care Management program, was implemented for clinically complex Medicaid beneficiaries who met risk criteria defined by a predictive modeling algorithm. We used propensity score matching to evaluate the program's impact on health care spending and utilization and mortality. We found large and significant reductions in inpatient hospital costs ($318 per member per month) among patients who used the program. The estimated reduction in overall medical costs of $248 per member per month exceeded the cost of the intervention but did not reach statistical significance. These results suggest that well-designed targeted care coordination services could reduce health care spending for Medicaid beneficiaries with complex health care needs.

The Development of a Community and Home‐Based Chronic Care Management Program for Older Adults

The objective of this paper was to evaluate a chronic care management program piloted by a visiting nurses association. Desired outcomes were to increase nurses' knowledge of self-management of chronic conditions and improve patient self-efficacy and clinical measures. The program provided educational development for nurses and piloted encounters with patients with chronic conditions targeting community health nurses for a chronic care professional (CCP) certification and invited 300 faith community nurses to an education program on chronic condition(s). Thirteen patients with chronic condition(s) were enrolled. Chronic care professional modules were used to increase nurses' knowledge and were measured by successful completion of a certification exam. Faith community nurses participated in an education program and completed a posttest to measure knowledge of content. Patient improvement in self-management was measured by pre- and postintervention self-efficacy scores and clinical measures. Seventeen nurses successfully completed the exam, and 38 faith community nurses participated in the program and completed the posttest. Three patients showed improvement in self-efficacy scores and eight in clinical measures. The educational development of community nurses prepared them to provide effective encounters to improve self-efficacy and clinical outcomes for older adults with chronic conditions.