Chronic Care Management in OMC’s Internal Medicine Clinic Reaches 200th Enrollee
By: Stacy Tintocalis, Freelance Writer
Chronic Care Management (CCM) at Ozarks Medical Center (OMC) Internal Medicine
Clinic in West Plains has reached its 200th enrollee, according to the clinic’s CCM nurse, Michelle McKee, LPN II-CCM.
OMC currently has Chronic Care Management in eight other clinics: OMC Alton,
OMC Gainesville, OMC Mammoth Springs, OMC Mountain Grove, OMC Mountain
View, OMC Thayer, OMC Winona, and OMC Urgent Care Clinic.
Chronic Care Management is a form of telephone-based case management for
patients who have two or more chronic conditions. CCM provides education
to help patients be better self-managers and establishes a comprehensive
care plan that is monitored, revised, and implemented in a three-way partnership
between the physician (or nurse practitioner), nurse, and patient.
Once in the CCM program, the patient’s doctor devises a care plan
for one year, and the CCM nurse coordinator contacts the patient at a
minimum of monthly, but sometimes weekly, depending on need. They also
see the patient at doctor’s visits about every 8 to 12 weeks.
CCM nurses get to know their patients and use phone conferences to focus
on the preventative services that CCM nurses offer such as relaxation
techniques; label reading; better sleep habits; exercises for flexibility,
strength and balance; and diabetes plate method. In January, OMC’s
CCM nurses also will train to be diabetes self-management educators.
According to Heather Hill, OMC Clinic Program Coordinator, CCM nurses are
responsible for scheduling annual wellness visits and other preventative
tests covered by Medicare. They can arrange transportation, perform thorough
medication checks, and enroll patients in programs, such as, Meals on
Wheels. “This is all in addition to monitoring the patients’
A1C, weight, or blood pressure, or other measures depending on the condition,”
Hill said. “The program is allowing us to provide extra support
to our patients, for example, when a patient is too ill to prepare food,
the CCM nurse coordinator can make sure meals are delivered to the patient.”
CCM nurses are easily accessible to the patients and are the liaisons
to the health care providers regarding any medical related condition the
patients may experience.
Patients with two or more chronic conditions may be eligible for CCM. According
to Medicare, chronic means the patient will live with the condition for
greater than 12 months. Individuals with the following chronic conditions
may be eligible for CCM:
- Alzheimer’s Disease and related dementia
- Arthritis (osteoarthritis and rheumatoid)
- Autism Spectrum Disorders
- Chronic Obstructive Pulmonary Disease (COPD)
- Congestive Heart Failure
- Heart Failure
- Ischemic Heart Disease
CCM is not limited to these conditions. A patient’s physician will
decide what is or is not chronic.
Each CCM nurse can manage up to 200 patients on the program. Currently,
OMC Gainesville, OMC Internal Medicine, OMC Mammoth Springs, and OMC Winona
have successfully enrolled 200 patients each. Spaces are available in
other OMC clinics.
Medicare and Medicare Advantage cover the majority of the cost of the program
so the patients have little or no out-of-pocket expense. For more information
on Chronic Care Management, call Heather Hill at 417-257-5889.
OMC’s Internal Medicine Clinic recently reached 200 patients enrolled
in their Chronic Care Management Program. Pictured left to right, front
row: Heather Hill, Clinics Program Coordinator and Michelle McKee, LPNII,
CCM Nurse. Back row: Aimee Jarrett, former Director of Clinics; Cheryl
Pleasant, Clinic Tech; D.J. Gross, APN; Kari Rogers, LPNII; Dr. Christopher
Cochran; and Julie Dockins, Office Assistant.