Chronic Care Management: Care That Keeps Going Between Visits

Owen: Think about how much happens when you're not at your provider's office. You take your medicines. You keep track of your numbers. You see specialists. And you handle whatever comes up in the weeks between visits.

Claire: That's true. The visit ends, and then it's all on me.

Claire: Thanks for joining us. You're listening to Between Visits, sponsored by Hope Health Network, a network of medical practices serving South Carolina. We dig into the medical and mental health topics that matter most to patients and the public.

Claire: I'm Claire, and this is episode 3. I'm going to quickly play our disclaimers, and then we'll get started!

Recorded disclaimer: This show is for entertainment, education and general information only. It's not medical advice, and listening doesn't make you a patient. Our hosts and guests are not real people, medical doctors or healthcare providers. We do our best, but we can be wrong, and our content can have errors and omissions. Talk with a licensed medical provider in your state before you make any decisions about your health or medical care.

Claire: In an emergency, call 911. In a crisis, call or text 988.

Claire: Joining me today is Owen, from our digital entertainment team. Welcome, Owen!

Owen: Happy to be here, Claire. Is that a new coffee mug?

Claire: It is. It holds about twice what the old one did.

Owen: So that's the secret to all this energy.

Claire: Today we're talking about Chronic Care Management: Care That Keeps Going Between Visits. Well, we're excited to get your thoughts on this important topic, Owen. Let's get started.

Claire: Today we're talking about something called Chronic Care Management. I'll be honest, that name doesn't tell me much. What is it?

Owen: It's a service for people living with more than one long-term health condition. You'll also hear it called C C M. In plain words, it's organized, ongoing help with conditions that need steady attention.

Claire: Okay, but I already see my provider. Why would I need something else?

Owen: Think about how much happens when you're not at your provider's office. You take your medicines. You keep track of your numbers. You see specialists. And you handle whatever comes up in the weeks between visits.

Claire: That's true. The visit ends, and then it's all on me.

Owen: That's the stretch of time this service is built for. The Centers for Medicare and Medicaid Services notes that it's typically provided outside of face-to-face visits.

Claire: So my care keeps moving even when I'm at work or busy with family?

Owen: Right. Or away on vacation.

Claire: Now I like the sound of that. My care coordinator keeps moving my care forward while I'm at the beach.

Owen: Something like that. The point is that your care doesn't have to wait for your next appointment.

Claire: Is this new?

Owen: Not really. Medicare began paying for it in 2015, to support the care that happens between office visits.

Claire: So who is it for? Who can get this?

Owen: Medicare dot gov says you must have two or more serious chronic conditions, like arthritis and diabetes, that you expect to last at least a year.

Claire: And chronic just means it's long-lasting?

Owen: That's the plain version. The Centers for Medicare and Medicaid Services describes conditions expected to last at least 12 months, or until the end of life. They also put a person at significant risk of death, a sudden flare-up or worsening, or a decline in how well they get through the day.

Claire: That's a mouthful. So, conditions that stick around and can really affect your life.

Owen: That's a good way to say it.

Claire: What kinds of conditions are we talking about?

Owen: The agency gives examples. They include high blood pressure, diabetes, heart disease, asthma, arthritis, cancer, glaucoma, and Alzheimer's disease and related dementia. And the list isn't limited to those.

Claire: Does mental health count? I'd think people might assume it doesn't.

Owen: It can. Depression and substance use disorders are on that same list, alongside things like diabetes and high blood pressure.

Claire: I didn't expect that. Okay, let me push back. Say I have high blood pressure and diabetes. That's two. So I'm in, right?

Owen: Not automatically. Having two diagnoses doesn't automatically mean this is right for you. Eligibility is a clinical decision your provider makes with you, based on your conditions and your needs.

Claire: So it's a conversation, not a checklist.

Owen: Exactly.

Claire: Okay, so what do I actually get? What's included?

Owen: Medicare describes it as a set of services you get on a monthly basis. It starts with a comprehensive care plan. That's a full plan for your care.

Claire: What's on it?

Owen: Your health problems and goals. Your other providers. Your medicines. The community services you have and need. And other information about your health.

Claire: So it's all in one place.

Owen: Yes. The Centers for Medicare and Medicaid Services also asks that the plan be patient-centered. That means it's built around you. It looks at your body and your mind, how you manage day to day, your surroundings, and the support you have.

Claire: So it's meant to be about my life, not just a list of diagnoses.

Owen: That's the idea. And you'd also get a review of your medicines and how you take them.

Claire: What else comes with it?

Owen: Support when you move from one care setting to another. That could be follow-up after an emergency room visit, or after you leave the hospital or a skilled nursing facility.

Claire: That seems like a time when things could get missed. I come home and I'm on my own.

Owen: Right. It's a moment when care can slip through the cracks. There's also a consistent member of your care team who stays in touch with you between visits and helps you manage your conditions.

Claire: So there's a member of my care team who knows me. How do I reach them?

Owen: Medicare's rules include ways to reach your care team by phone and through secure messaging. There's also help making sure you get recommended preventive care on time.

Claire: And what about my specialists? Will they know about this plan?

Owen: The agency asks practices to make the plan available to your other practitioners. That way, everyone works from the same plan.

Claire: Okay. That's what Medicare's rules say. How does it work at Hope in real life?

Owen: At Hope Integrative Medicine, a member of Hope Health Network, you get a customized care plan that captures your care goals, based on what's important to you. Your care coordinators work closely with your provider. Every month, they track, revisit and chart your progress toward those goals.

Claire: Every month. And can I text them, or is it all phone calls?

Owen: You can. Enrolled patients can reach the care coordination team through secure text messaging. They're someone you can go to with questions about your care.

Claire: What if it's an emergency? Should I text then?

Owen: No. Hope Integrative Medicine is not an emergency service. In an emergency, call 911.

Claire: Good to be clear on that. What else does the team do?

Owen: Your full care team, at Hope and among the outside specialists involved in your care, is kept up to date on your care events and your progress. The team also tracks trends in your care over time.

Claire: Trends. Like what, exactly?

Owen: It gives you and your providers a bird's-eye view of your progress, or your challenges, over time.

Claire: So you can see the big picture, not just one day. How do people feel about having someone check in like that?

Owen: Patients tell the practice they really appreciate their care coordinators checking in between visits. Over time, they build a personal relationship with this extended team.

Claire: You said earlier that depression and substance use can count. How does that fit in here?

Owen: Hope offers primary care, mental health care and addiction medicine in the same practice. So when your conditions span more than one of those areas, your care plan can too.

Claire: So it's one plan, not three separate ones.

Owen: Right. And your care coordinators can keep all of your providers working from that same plan.

Claire: All right. How does somebody get started?

Owen: It starts with a visit with your provider. If you're new to Hope, or it's been more than a year since your last visit, that visit comes first.

Claire: What kind of visit?

Owen: It can be a comprehensive visit, an annual wellness visit or an initial preventive physical exam.

Claire: And after that I'm signed up?

Owen: Not until you agree. Before it begins, the team explains the service, including any cost-sharing under your coverage, and asks for your consent.

Claire: Cost-sharing. That's the part everybody wants to know about. Does insurance cover this? And is it only for people on Medicare?

Owen: Medicare covers it for eligible patients, and many other plans may too. Cost-sharing applies. With Original Medicare, that means things like the Part B deductible and 20 percent coinsurance.

Claire: In regular words, please.

Owen: Cost-sharing is the part of the bill that may be yours to pay. The team explains it before you start. Coverage rules can change, so check with your plan for your own costs.

Claire: Fair enough. Can I do this with two different offices, if I see more than one?

Owen: Medicare allows only one practice to provide it for you in a given calendar month. So your care has one home base.

Claire: And if I change my mind?

Owen: It's your choice. You can stop at any time. Under Medicare's rules, stopping takes effect at the end of the calendar month.

Claire: If someone's listening and wondering if this fits them, what could they ask?

Owen: Here's a simple one. Do my conditions make me a candidate for Chronic Care Management, and what would my care plan focus on?

Claire: I like that. You could write that down and take it with you. Do you have to wait for your next visit to ask?

Owen: No. You can bring it up at your next visit, send a message or call the office. The team will check whether it's right for you.

Claire: Okay, before we wrap up. If people only remember a few things from today, what should they be?

Owen: First, this service is for people with two or more long-term conditions, and most of it happens between visits.

Claire: Okay. What else?

Owen: Second, two diagnoses don't qualify you on their own. You and your provider decide together.

Claire: And one more?

Owen: It starts with a visit and your consent, and you can stop at any time.

Claire: That's really helpful. Thank you for walking us through this.

Owen: Thanks for having me, Claire. I hope it helps someone.

Claire: This episode is sponsored by Hope Health Network. Its member practices all have providers experienced in chronic care management, or can refer you to a network provider who is. Hope Health Network medical practices provide evidence-based medical care and include Hope Integrative Medicine, Hope Medical Associates, Hope Behavioral Medicine and Hope Addiction Medicine. To learn more, go to Hope Health Network dot com. That website, along with appointment links for all four practices, is in the description of this episode.

Claire: One last reminder. In an emergency, call 911. In a crisis, call or text 988.

Claire: This podcast is a production of Hope Health Network Media.

Claire: You've been listening to episode 3 of Between Visits, Chronic Care Management: Care That Keeps Going Between Visits. Thanks for hanging out with us. See you next time!