Living with a chronic condition does not mean you cannot lead a better life. It is possible for people facing more than one chronic illness to achieve physical fitness, reduced stress, better sleep, and increased mobility.

The National Center for Health Statistics defines a chronic condition as a disease that lasts for more than three months. According to the Office of the Assistant Secretary of Health, about 3 in 4 senior citizens in the United States are suffering from multiple chronic conditions, unfortunately.

Such conditions include but are not limited to, multiple sclerosis, lupus, autism, arthritis, dementia, cancer, asthma, depression, hypertension, Alzheimer’s disease, HIV/AIDS, and/or other infectious diseases.

Chronic care management (CCM) has thus been designed to enhance the quality of patients’ lives. Let’s understand what comprises CCM in detail:

What Constitutes Chronic Care Management?

According to the Centers for Medicare and Medicaid Services (CMS), CCM is:
“Care coordination services done outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline”.

This outlines the eligibility criteria for you to be accepted for CCM. However, don’t feel alarmed by this definition. The whole purpose of chronic care management is to reduce your stress and improve your health and wellbeing.
You don’t just have to exist because of your illness. Through CCM, you will gradually become physically fit and active, and we at AdvantagePlusNurses make sure that you are an inherent part of the care plan.

What’s Your Role in It?

How exactly do we make you more independent and proactive? That’s a good question. We understand that chronic diseases do lead to a certain degree of disability to a person’s life in terms of performing daily chores and managing personal care.

However, we reduce your dependence on others by focusing on individual behavior. Research suggests that better health outcomes can be achieved by involving patients in the decision-making process.

That’s what we do at AdvantagePlusNurses. Through CCM, you learn to manage your health proactively and effectively. We do so by educating you on how to take charge of monitoring your vitals every day.

You communicate with our team regularly, which eventually improves your engagement. Besides, we ensure continuity in care by assigning you a dedicated Care Specialist who you can contact anytime and feel comfortable engaging with.

We make realistic goals for you to achieve in a specific timeframe, and when you do achieve them, it automatically boosts your confidence!

Patient-Centric Care Plan

Chronic care management is not a one-size-fits-all program. The greatest benefit of CCM is that it’s tailored to your values, choices, and needs, which may or may not apply to the other patients.

For instance, every person has unique environmental factors and cognitive ability that requires unique care. These factors influence the patient’s ability to respond.

Therefore, here at AdvantagePlusNurses, we hold counseling sessions to address those specific needs and incorporate them into your care plan.

Easing the Transition Between Care Settings

Fragmentation of care has been a major challenge for chronic patients. They receive treatment from multiple healthcare providers. As a result, they encounter conflicting opinions about their condition.

The differing treatment protocols, frequent visitations between care settings is even more debilitating than the disease itself. Not surprisingly, it leads to increased risk of hospitalization and mortality with time.

Thus, the patient feels drowned in constant stress and anxiety, further reducing his or her chance of responding reasonably to the treatment. Moreover, it adds to the burden of an overstretched healthcare system of the country.

Transitional Care Management

The CCM has provisions for recording all patient data electronically. This record holds every piece of information, including past care providers, medical history, patient’s conditions, demographics, allergies, and medications.

Why is this necessary? Transitional care management closes the loopholes in our healthcare system. It facilitates your care between the different care settings so that you get ample time to recover.

During the transition from home to hospital, hospital to home, or between two different hospitals, the electronic health record (EHR) helps your care providers understand relevant data on your condition – both past and present.

Enhanced and Secure Communication

As we mentioned before, a member of our team will be in charge of taking care of you. You can contact the person 24/7 for any questions you may have or in case of an emergency. The communication will be mostly telephonic.

However, we will provide you additional means of communication such as a messaging service through our mobile application and tablet. These are entirely secure channels built using the latest technology.

Hence, you never have to worry about losing your data.

Try our services to access all of the above features of chronic care management!

Leave a comment