Chronic Care Management at Oklahoma Heart Hospital

Chronic health issues can be some of the hardest things to live with, but we’re here to help.

With Medicare’s Chronic Care Management guidelines, patients with multiple chronic conditions can get the care they need with streamlined support to improve outcomes. 

What is Chronic Care Management?

Oklahoma Heart Hospital strives to provide high-quality, individualized patient care to every patient, but Chronic Care Management is a unique program. It’s a separate Medicare service provided to people with multiple chronic conditions.

A CCM plan requires several parts to qualify under Medicare guidelines:

• A list of problems that need to be managed.
• Expected outcome of the chronic disease or infirmity.
• Treatment goals that are measurable and attainable.
• Symptom management through a long-term plan.  
• Planned interventions or times when medical professionals or other providers will check in with the patient or provide specific services. 
• Identification of individuals involved. Only one practitioner is allowed to be on the bill for a CCM patient per month, though they may have people under them.
• Medication management. Chronic care requires an understanding of what medications are needed and a plan for prescriptions that will be used.
• Community/social services ordered. When you’re dealing with a chronic care situation, these are often included.
• Description of coordinated services outside of main practice. If there are extra services needed, they must be taken care of by the main practitioner’s office and laid out in the CCM plan.
• Review and revision periods scheduled in advance.

One of the biggest benefits of CCM is continuity of care. Because of the way the program is set up, it requires communication between the patient and one key contact. Then that key contact takes care of community, social, medication, and other needs and helps the patient stick to the plan.

CCM providers are also responsible for helping with any care transitions between their practice and another practice.

CCM at Oklahoma Heart Hospital

Here at Oklahoma Heart Hospital, we’re involved in complex chronic care for many patients. We have the experience and the systems in place to make your chronic care the best it can be.

Heart conditions are one of the biggest needs for patients that have a CCM plan, and we’ve been involved with this program for a long time. We help patients with medication reconciliation, provide blood pressure cuffs and scales for those who need them to manage their health, and answer any questions patients may have. We work with the patient and their other providers to obtain outside records and reduce the costs of repeat testing plus provide education around diet, exercise, and medication management. 

If you have any questions about Chronic Care Management or other services, contact us today and find out what Oklahoma Heart Hospital can do for you.