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Chronic Care Management Services for Complex Diabetes Management: a Practical Overview.

Kayla L Del Valle1, Marie E McDonnell2

  • 1Brigham and Women's Hospital, Division of Endocrinology, Harvard Medical School, 221 Longwood Avenue, Suite 381, Boston, MA, 02115, USA.

Current Diabetes Reports
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PubMed
Summary

Formalized chronic care management shows promise for complex diabetes care. Integrating the Chronic Care Model with telehealth and current Medicare reimbursement offers a path forward, despite existing barriers.

Keywords:
Chronic care managementChronic care modelComplex diabetesDiabetesType 1 diabetesType 2 diabetesVirtual care

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Area of Science:

  • Endocrinology
  • Health Services Research
  • Geriatrics

Background:

  • The Chronic Care Model (CCM) has evolved to emphasize proactive management of chronic diseases.
  • Medicare introduced Chronic Care Management Services (CCMS) in 2015 to support patients with multiple chronic conditions.
  • Formalized CCM shows potential for improving quality and cost-effectiveness in adult diabetes management.

Purpose of the Study:

  • To review the application of the CCM in complex diabetes care.
  • To examine the translation of CCM principles within the current Centers for Medicare and Medicaid Services (CMS) reimbursement structure.
  • To explore strategies for effective diabetes CCM, including telehealth and remote monitoring.

Main Methods:

  • Literature review of CCM applications in diabetes.
  • Analysis of current CMS reimbursement policies for CCMS.
  • Synthesis of evidence on telehealth and remote monitoring in diabetes management.

Main Results:

  • CCM is supported by evidence for improving diabetes care outcomes.
  • Medicare's CCMS reimbursement allows for dedicated clinical staff time within comprehensive care plans.
  • Combining goal-oriented care with telehealth solutions is effective for diabetes CCM.
  • Barriers to widespread CCM adoption in standard practice persist.

Conclusions:

  • Formalized CCM, particularly when integrated with telehealth, offers a viable strategy for complex diabetes management.
  • Adapting CCM to the existing reimbursement landscape is crucial for sustainable implementation.
  • Addressing systemic barriers is necessary to fully realize the benefits of CCM in diabetes care.