Chronic Care Management

Chronic Care Management

What is Chronic Care Management?

Chronic Care Management (CCM) was developed by Medicare after research showed the program helped patients manage their chronic diseases, decrease their admissions to hospitals, and decrease ER visits.

To participate in the Medicare CCM program:

  • Identify qualified Medicare patients with two or more chronic conditions that last more than 12 months or until death
  • Create a care plan, develop a Patient Consent Form, and have patients sign the form.
  • Provide 20 minutes or more of non-face-to-face chronic care per month per patient.
  • Only one provider can bill this for each patient.
  • Services can be billed every month.
  • Use a certified EHR.
  • Provide 24/7 access for beneficiaries to care plan.
  • Coordinate care, manage referrals and share data electronically with other provider.

Program Background at Gothenburg Health:

  • Started gathering information and data in August 2017 and hired a fulltime chronic care nurse
  • First patients on-boarded in January of 2018 with a focus on diabetes
  • Change in nurses in July 2018, and regained momentum
  • Next group of patients we are focusing on is Congestive Health Failure (CHF), letters were sent in early December about program to get patients thinking and follow-up will begin in January with this group to start onboarding.

Chronic Care Nurse: Shay Holbrook RN-BSN

  • Started working at Gothenburg Health in 2012 as a CNA on Acute
  • 2014 attended nursing school in North Platte and became a registered nurse in 2016
  • 2016 took first RN job in the ICU at Great Plains Health
  • Oct 2016 started back at Gothenburg Health in the surgery department
  • May 2018 finished bachelors degree in nursing
  • July 2018 transferred to the clinic as the chronic care nurse

How does it improve my health?

  • Implement and help you achieve health goals you set
  • Work with your other providers so all of your care team is working to help you with your health care goals.
  • Assist with medication understanding and management
  • Provide any educational needs
  • Support system
  • Help you keep up to date on all preventive care
  • Help with resources needed

Call the Medical Clinic at Gothenburg Health to learn more: 308-537-4066.