What is Chronic Care Management?
Chronic Care Management is an initiative started by the Center for Medicare and Medicaid Services (CMS) to encourage medical practices to identify patients with two or more chronic conditions, determine changes in their health, and to help manage these changes. The program is a preventative measure in order to avoid unnecessary emergency room or hospital visits. It is also meant to minimize readmission to hospitals after patient release.
What are chronic conditions?
The Centers for Disease Control and Prevention defines a chronic condition as any condition that has been ongoing for more than one year and requires prolonged medical care. Chronic conditions are also defined as those that limit the patient’s ability to perform basic activities of daily living (ADLs). Activities of daily living include eating (feeding themselves), bathing, dressing, toileting (the ability to independently use the toilet and perform personal hygiene), transferring (the ability to independently get in and out of a bed or chair), and the ability to maintain continence (bladder and bowel control).
The Center for Medicare and Medicaid Services has identified the list below as chronic conditions. Along with these medical conditions, Urologic chronic conditions include Benign Prostatic Hyperplasia (BPH), Overactive Bladder (OAB), bladder cancer, prostate cancer, and renal cell cancer.
CMS list of chronic conditions
- Alzheimer’s disease/Dementia
- Atrial fibrillation
- Autism Spectrum Disorders
- Chronic kidney disease
- Chronic obstructive pulmonary disease (COPD)
- Heart failure
- Hepatitis (Viral B & C)
- Hyperlipidemia (high cholesterol)
- Hypertension (high blood pressure)
- Ischemic heart disease (coronary artery disease) – reduced blood flow due to plaque build-up in the arteries
- Schizophrenia and other psychotic disorders
Chronic Care Management at Urology Centers of Alabama
Because Urology Centers of Alabama understands the interaction of disease states, and the importance of providing top quality patient healthcare, we have established a new Chronic Care Management program for patients who have two or more chronic conditions and are covered by Medicare. Medicare patients who choose to participate, will receive a monthly phone call from a Care Team Coordinator to review and help manage their chronic conditions.
Care Team Coordinators work with our patients each month to:
- Assess their current conditions, symptoms, and medical care progress
- Answer patient questions about their medical conditions and treatments
- Review their current medications
- To ensure that patients are receiving medical attention in a timely manner
- To assist patients with transitioning their care to the necessary medical providers
- Assist patients with physician referrals and authorizations
- Ensure that their billing questions are answered