Chronic Care Management

What is Chronic Care Management?

Chronic Care Management is an initiative started by the Center for Medicare and Medicaid Services (CMS) to encourage medical practices to identify patients with two or more chronic conditions, determine changes in their health, and to help manage these changes. The program is a preventative measure to avoid unnecessary emergency room or hospital visits. It is also meant to minimize readmission to hospitals after patient release.

What are chronic conditions?

The Centers for Disease Control and Prevention defines a chronic condition as any condition that has been ongoing for more than one year and requires prolonged medical care. Chronic conditions are also defined as those that limit the patient’s ability to perform basic activities of daily living (ADLs). Activities of daily living include eating (feeding themselves), bathing, dressing, toileting (the ability to independently use the toilet and perform personal hygiene), transferring (the ability to independently get in and out of a bed or chair), and the ability to maintain continence (bladder and bowel control).

The Center for Medicare and Medicaid Services has identified the list below as chronic conditions. Along with these medical conditions, Urologic chronic conditions include Benign Prostatic Hyperplasia (BPH), Overactive Bladder (OAB), Bladder Cancer, Renal Cancer, Prostate Cancer, Ureter Cancer and Renal Pelvis Cancer.

CMS list of chronic conditions include but are not limited to:

Alzheimer’s disease/Dementia
Arthritis
Asthma
Atrial fibrillation
Autism Spectrum Disorders
Cancer
Chronic kidney disease
Chronic obstructive pulmonary disease (COPD)
Depression
Diabetes
Heart failure
Hepatitis (Viral B & C)
HIV/AIDS
Hyperlipidemia (high cholesterol)
Hypertension (high blood pressure)
Ischemic heart disease (coronary artery disease) – reduced blood flow due to plaque build-up in the arteries
Osteoporosis
Schizophrenia and other psychotic disorders
Stroke