Chronic Care Management
An effective Chronic Care Management program must include 4 basic components
Patients have a disease specific, dedicated care manager (same care manager every touchpoint), that reaches out to the patient, all clinicians and services (pharmacies, DME, meals on wheels etc) involved in the patients care
The end goal is to ensure that all providers are on the same page. All providers will receive an updated care plan monthly uploaded to their EMRs in which they can see what everyone else is doing for the patient. Most importantly, the patient receives an updated care plan every month.
CCM Program Results
Average HbA1C of Pts With Diagnosis of Type 2 DM Before entering CCM Program: Date Range (01/01/17 - 12/31/17)
Average HbA1C of Pts With Diagnosis of Type 2 DM After entering Frontizo CCM Program: Date Range (01/01/18 - 12/22/18)
- Overall Decrease in HbA1c by 1.5% which is roughly equivalent to 45 mg/dL decrease
- Out of 500 patients, 255 with HGbA1c > 9 was decreased to 79 in one year
# of COPD Exacerbations Before entering CCM Program: Date Range (01/01/17 - 12/31/17)
# of COPD Exacerbations After entering Frontizo CCM Program: Date Range (01/01/18 - 12/22/18)
- Average number of yearly COPD exacerbations per patient per year was 3.03; After the Frontizo program averaged 2.51 exacerbations per year
- 136 COPD exacerbations resulting in a 30 day readmit pre-program. Post-program 71 episodes of COPD exacerbations resulting in 30 day readmit.