A Platform and Clinical Model to Enable Medicare's Chronic Care Management Program

Area of Science:

• Health Services Research
• Gerontology
• Health Informatics

Background:

• The Centers for Medicare & Medicaid Services (CMS) introduced the chronic care management (CCM) benefit in 2015.
• Studies indicate CCM improves advance care planning and reduces healthcare costs.
• Despite proven benefits, the CCM program experiences low utilization rates.

Purpose of the Study:

• To develop a scalable platform for implementing the Medicare CCM program.
• To identify clinical and utilization risk factors associated with hospitalization in CCM patients.
• To report on the outcomes of a technology-enabled CCM service model.

Main Methods:

• A technology and integrated clinical staff platform was developed for scalable CCM implementation.
• Care management data elements were used to flag risks like falls, mortality, hospitalization, and polypharmacy.
• Logistic regression analyses identified risk factors for hospitalization in a cohort of 26,500 patients.

Main Results:

• The CCM cohort experienced 2679 hospitalizations (184 per 1000 patient-months).
• Higher Gagne mortality risk significantly increased hospitalization odds (32x) in non-nursing home residents.
• Nursing home residency and unassisted ambulation predicted higher hospitalization, while high hospitalization risk flags and low fall/polypharmacy risk predicted lower hospitalization.

Conclusions:

• The developed CCM model offers a scalable approach to managing patients with multiple chronic conditions.
• This model effectively identifies patients at high risk for hospitalization.
• Targeted interventions based on identified risk factors can potentially reduce hospitalizations and improve outcomes.