A Pilot to Implement Chronic Care Management Services at an Academic Medical Center

Area of Science:

• Geriatrics
• Health Services Research
• Internal Medicine

Background:

• Effective care coordination is essential for Chronic Care Management (CCM).
• House call programs can integrate CCM services to enhance patient care.
• Pilot studies are crucial for evaluating new service implementations and reimbursement models.

Purpose of the Study:

• To describe the implementation of CCM services within an academic medical center's house call program.
• To identify the processes involved in delivering non-face-to-face CCM services.
• To verify the reimbursement potential of CCM services in a house call setting.

Main Methods:

• A pilot study and retrospective review of patients enrolled in CCM.
• Patient identification via a registry, followed by care plan documentation and patient follow-up calls.
• Inclusion criteria: patients aged 65+ with multiple chronic conditions.

Main Results:

• Twenty-three patients participated, with a mean age of 82 years; 67% were White.
• Total reimbursement collected for CCM services was $1,066, with a traditional Medicare co-pay of $8.47.
• Common diagnoses included hypertension, congestive heart failure, chronic kidney disease, dementia, and type 2 diabetes mellitus.

Conclusions:

• CCM services can serve as an additional revenue stream for healthcare practices.
• Integrating CCM into house call programs enhances care coordination for chronic disease management.
• The pilot demonstrated the feasibility and financial benefits of providing CCM services remotely.