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

In 2015, the Centers for Medicare & Medicaid Services (CMS) implemented a new benefit called chronic care management (CCM). A recent CMS-commissioned study of the program showed that CCM is effective in increasing advance care planning and decreasing overall costs. Despite positive effects on care planning, utilization, and cost, the CCM program remains underutilized. The authors sought to develop a platform to enable scale of the CCM program, and to report outcomes associated with its use. A technology and integrated clinical staff platform was built to enable a scalable, evidence-based implementation of the Medicare CCM program. The model created care management data elements that were used to flag clinical and utilization risks such as falls, mortality, hospitalization and polypharmacy. In 2018, CCM support was provided for 26,500 patients. Logistic regression analyses were used to identify risk factors associated with hospitalization. The cohort experienced 2679 hospitalizations (184 admissions per 1000 patient months per year). Among patients residing in non-nursing home settings, a higher Gagne mortality risk was associated with a 32 times greater chance of being hospitalized. Other positive predictors of hospitalization included being a nursing home resident and being ambulatory without assistance. Negative predictors of hospitalization included being flagged as having a high hospitalization risk, and scoring in the low-risk category for falls or polypharmacy. This CCM model is a scalable method of supporting care management for people with multiple chronic conditions, and can help identify risk factors for hospitalization.