Magazine Article | September 28, 2015

Using Analytics To Build Personalized Plans For Chronic Care Management

Source: Health IT Outcomes

Compiled by Amanda Griffith, Contributing Writer

Wake Forest Baptist Medical Center is leveraging functional status assessments and social determinants of health to advance its population health management efforts.

Medicare has implemented three programs to improve management of individuals with chronic conditions: Medicare Annual Wellness Visit, Transitional Care Management Reimbursement, and Chronic Care Management (CCM) Payment. The CCM Payment improves physician reimbursement related to the care of individuals with complex chronic conditions. The fee expands this strategy to all primary care practices serving Medicare beneficiaries and represents a critical step forward in recognizing that the essential features of primary care — continuity, whole-person focus, comprehensiveness, serving as patients’ first contact for new health issues, and coordination — are not optimally supported by the fee-for-service model.

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