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The Importance of Chronic Care Management Today

13 July 2020
Blog

eClinicalWorks

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I believe that Chronic Care Management (CCM) is one of the best tools that has ever been given to healthcare providers. I started using CCM in my office in October 2014 — a year before it became a benefit— because I’ve always believed healthcare was a team sport.

I primarily work with patients in their 80s. Many of these patients have chronic conditions, and prior to CCM, I would provide them with a care plan and pray that they’d follow my instructions until the next office visit. By adopting CCM, we had a tool that helped form a concrete team where each person had a role that could be carried out in between visits to ensure better care for these at-risk patients.

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During the COVID-19 pandemic, we closed our main office and would only let patients come in for emergency visits. As soon as we made this decision, I compiled a list of chronic care patients and created a phone call system. This system calls patients once a week and asks them questions about problems they may be facing during the pandemic.

We quickly learned that there was going to be a shortage of certain medications during the pandemic. Luckily, since I had a list of our chronic care patients, I was able to send all of the CCM patients a 90-day supply of their medication. After that, we called them on a weekly basis and touched base with them to ensure there was nothing that they were missing.

I think we are really underestimating cases of PTSD that could come from feeling isolated during the virus. I continue to try to do everything possible to ensure that people in the CCM group understand that they’re not alone.

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Many of the CCM patients are very sick, and family input has been important. During the pandemic, families of patients undergoing chemotherapy didn’t know how to get masks. Some of our patients who are seamstresses quickly stitched together masks and provided them to the families of patients who were going for chemotherapy. It was such an incredible thing to see that the patients felt safe; it took away their fear of coming into a doctor’s office.

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