Chronic Care Management Template

What is a Chronic Care Management Template?

A Chronic Care Management (CCM) template is a structured framework or document used in healthcare settings to facilitate the coordination and management of care for patients with chronic conditions. It serves as a guideline or tool for healthcare providers to systematically organize and track the care provided to patients with ongoing health needs. This management tool allows for care coordination that falls outside of regular practice visits for patients who have multiple chronic conditions, all of which are expected to be present over the next 12-month period or with a significant risk of death or functional decline. 

A chronic condition is a long-lasting health condition that persists over an extended period, typically three months or more. These conditions often require ongoing medical attention and may limit a person's daily activities or quality of life. Chronic conditions can range from mild to severe and may fluctuate in intensity over time. A carefully created management plan is key to the successful delivery of healthcare. 

A CCM outlines specific details about the chronic conditions the patient is managing, including diagnoses, treatment plans, and care goals. The management plan will clearly show the interventions, treatments, and care goals tailored to the patient's chronic conditions and may include medication management, lifestyle recommendations, preventive care, and monitoring guidelines. The management of chronic patients needs to rely on patient-centered care with a team of healthcare professionals and family members alongside the patient all on the same page. In terms of the coordination of care, chronic care management templates allow for information about various healthcare services and resources to be readily available to the patient.

Creating a chronic care management plan enhances patient engagement by promoting self-management, educating patients about their conditions, and empowering them to make informed decisions about their health. A chronic care management plan allows for the opportunity to address health equity. It emphasizes personalized care tailored to the needs of individual patients, helping to bridge the gaps in healthcare disparities and ensuring equitable access to quality care for all patients.

Chronic care management is typically created and utilized for patients with one or more of the following chronic conditions:

• Diabetes
• Hypertension
• Heart Disease
• Chronic Obstructive Pulmonary Disease (COPD)
• Asthma
• Arthritis
• Chronic Kidney Disease (CKD)
• Mental health Conditions

How does it work?

Step 1: Gather your resources

Chronic care management templates are a valuable resource and essential to keep on hand. Make sure that you have a copy of the free printable PDF when the need arises by either clicking the “Download Template” or “Use Template” button or by searching “ Chronic care management template” on Carepatron’s template library’s search bar on the website or app.

Step 2: Collate essential information

Once the patient has been flagged for chronic condition management by a healthcare professional, utilizing the chronic care management template helps to ensure all goals of care are met and seamlessly and easily accessible to relevant parties via Carepatron's centralized workspace. The patient's information can be collected and stored within the document and relevant care plan aspects can be charted for. The care plan allows for individualized treatment options and acts as a scaffolding to ensure goals of care are met, and the next steps are recorded for future reference or for distribution to other healthcare specialists who are part of the patient's care team.

Step 3: Store the chart securely

After reviewing the chronic care management template and creating a viable and individualized plan for the patient, you need to secure the plan so that access is only granted to relevant parties.

Ensure this through Carepatrons HIPAA-compliant free patient records software. Here, all relevant medical records can be safely stored and collated for ease and security.

When would you use this Template?

A Chronic Care Management (CCM) Template is utilized in healthcare settings to streamline and organize the comprehensive care for patients with chronic or long-term health conditions. Here are some key scenarios where a template would be used:

Initial Assessment and Care Planning

When a patient is diagnosed with a chronic condition, healthcare providers use a CCM template to gather comprehensive information during the initial assessment. This includes medical history, current medications, lifestyle factors, and assessment of the condition's impact on the patient's life.

Creating Individualized Care Plans

Based on the assessment data, healthcare professionals develop individualized care plans tailored to the patient's specific needs. A CCM template is a structured framework to outline interventions, goals, and strategies for managing chronic conditions effectively.

Care Coordination and Collaboration

When multiple healthcare providers are involved in a patient's care, a CCM template facilitates communication and coordination among different providers. It ensures that all involved parties access relevant information and follow a cohesive care plan.

Ongoing Monitoring and Management

CCM templates are utilized to monitor the patient's health status, track progress, and make necessary adjustments to the care plan. Regular assessments and updates help ensure that the patient's needs are continuously addressed.

Patient Education and Empowerment

The template includes provisions for patient education materials and strategies to empower patients to manage their condition effectively. It outlines educational resources, self-management techniques, and lifestyle recommendations.

Documentation and Reporting

Healthcare providers use CCM templates to document patient encounters, interventions provided, outcomes, and any changes in the care plan. This documentation is essential for reporting, billing, and maintaining a comprehensive patient record.

Transition of Care

During transitions between care settings (e.g., from hospital to home or between healthcare providers), CCM templates aid in ensuring continuity of care. They guide the transfer of information and care plans, minimizing gaps in care.

Quality Improvement and Evaluation

CCM templates support quality improvement initiatives by enabling healthcare organizations to evaluate the effectiveness of their chronic care management programs. They provide a basis for assessing outcomes and identifying areas for improvement.

In summary, a Chronic Care Management Template is used throughout the continuum of care for patients with chronic conditions, from initial assessment to ongoing management, focusing on delivering comprehensive, coordinated, and patient-centered care.

Utilize our care plan template for a complete approach to client health issues.

Who can benefit from Chronic Care Management?

Chronic care management (CCM) programs are primarily designed and implemented for patients with chronic or long-term health conditions. These programs aim to provide comprehensive and coordinated care to individuals dealing with ongoing health needs.

Patients who benefit most from chronic care management often have one or more chronic conditions such as:

Diabetes

Both type 1 and type 2 diabetes require continuous management of blood sugar levels, medication adherence, lifestyle modifications, and regular monitoring to prevent complications.

Hypertension (High Blood Pressure)

Long-term blood pressure management through medication, lifestyle changes, and regular check-ups is crucial to reduce the risk of cardiovascular issues.

Heart Disease

Patients with coronary artery disease, heart failure, or other cardiac conditions benefit from ongoing care to manage symptoms, medications, and lifestyle adjustments to prevent the worsening of their condition.

Chronic Obstructive Pulmonary Disease (COPD)

Patients with COPD require ongoing support for managing breathing difficulties, medications, pulmonary rehabilitation, and lifestyle changes.

Asthma

Chronic asthma management involves education on triggers, proper use of medications (such as inhalers), and monitoring to prevent exacerbations.

Arthritis

Ongoing support is beneficial for patients with chronic joint pain, helping manage symptoms, maintain mobility, and prevent further joint damage.

Chronic Kidney Disease (CKD)

Patients with CKD require continuous monitoring of kidney function, medication management, dietary guidance, and education to slow the progression of the disease.

Mental Health Conditions

Chronic care management is also valuable for individuals dealing with ongoing mental health conditions like depression, anxiety disorders, bipolar disorder, and schizophrenia. It involves medication management, therapy, and support for symptom management and functional improvement.

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These conditions often require ongoing medical attention, lifestyle modifications, medication adherence, regular monitoring, and coordination among healthcare providers. Chronic care management programs aim to support patients in managing these conditions effectively, improving their quality of life, and reducing the risk of complications or hospitalizations associated with chronic illnesses.

Research & evidence

Chronic diseases significantly impact individuals in both developed and developing nations. Out of the 57 million deaths recorded in 2008, 63% were directly attributed to chronic diseases, notably cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. Disturbingly, nine million of these deaths occurred in individuals under 60 years old, with ninety percent of these premature fatalities happening in low- and middle-income countries (Alwan et al., 2010). Additionally, disadvantaged communities in developed countries also face a growing burden of chronic illnesses (World Health Organization, 2011).

Researchers have sought to establish comprehensive strategies for managing chronic diseases and enhancing care delivery to counter this escalating health challenge. The foundational principles of numerous current chronic disease management approaches were initially outlined by the MacColl Institute for Healthcare Innovation at Group Health Cooperative, known as the Wagner chronic care model (Wagner CCM). This model identified six crucial elements: community resource mobilization, high-quality care promotion, patient self-management facilitation, evidence-based and patient-preference-aligned care, effective utilization of patient and population data, cultural competency, care coordination, and health promotion (Rea et al., 2007). However, while these broad elements align with the Wagner CCM, the definition and execution of a CCM within healthcare services have continued to develop and evolve (Ouwens et al., 2005).

References

Alwan, A., MacLean, D. R., Riley, L. M., d’Espaignet, E. T., Mathers, C. D., Stevens, G. A., & Bettcher, D. (2010). Monitoring and surveillance of chronic non-communicable diseases: progress and capacity in high-burden countries. The Lancet, 376(9755), 1861–1868. https://doi.org/10.1016/s0140-6736(10)61853-3

Glasgow, R. E., Tracy Orleans, C., Wagner, E. H., Curry, S. J., & Solberg, L. I. (2001). Does the Chronic Care Model Serve Also as a Template for Improving Prevention? The Milbank Quarterly, 79(4), 579–612. https://doi.org/10.1111/1468-0009.00222

Ouwens, M., Wollersheim, H., Hermens, R., Hulscher, M., & Grol, R. (2005). Integrated care programmes for chronically ill patients: a review of systematic reviews. International Journal for Quality in Health Care : Journal of the International Society for Quality in Health Care, 17(2), 141–146. https://doi.org/10.1093/intqhc/mzi016

Rea, H., Kenealy, T., Wellingham, J., Sinclair, G., McAuley, S., Goodman, M., & Arcus, K. (2007). Chronic care management evolves towards integrated care in Counties Manukau, New Zealand. He New Zealand Medical Journal (Online), 120(1252).

World Health Organization. (2011). Noncommunicable diseases country profiles 2011. WHO.