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Ozarks Medical Center Adds Ninth Clinic with Chronic Care Management

Ozarks Medical Center Adds Ninth Clinic with Chronic Care Management

By: Stacy Tintocalis, Freelance Writer

Recently, Ozarks Medical Center (OMC) rolled out Chronic Care Management (CCM) in OMC Urgent Care Clinic. OMC currently has CCM in eight other clinics: OMC Alton, OMC Gainesville, OMC Mammoth Springs, OMC Mountain Grove, OMC Mountain View, OMC Thayer, OMC Winona, and OMC Internal Medicine in West Plains.

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 will also 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)
  • Asthma
  • Autism Spectrum Disorders
  • Cancer
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Congestive Heart Failure
  • Depression
  • Diabetes
  • Heart Failure
  • Hypertension
  • Ischemic Heart Disease
  • Obesity
  • Osteoporosis

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 Winona recently reached 200 patients enrolled in their Chronic Care Management Program. Staff at OMC Winona include, Front Row: Aimee Hilt, Clinic Director; Ashley VanWinkle, LPNII; Back Row: Heather Hill, Clinics Program Coordinator; Barbara Honeycutt, LPN II; Dr. Diane Koenig; Windy Horton, LPNII-Chronic Care Management Nurse; Angie Smith, EVS; and Susan Lindsey, Clinic Supervisor.

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