IMPLEMENTATION AND EVALUATION OF CHRONIC CARE MANAGEMENT PROGRAM: A CLINICAL PRACTICE CHANGE

The increasing size of the chronically ill elderly Medicare population and its projected growth are a major challenge to the health care systems in the United States. This ongoing pilot study compares outcomes before and after a Chronic Care Management Program (CCMP) was implemented on 36 elderly Medicare beneficiaries with two or more chronic conditions in a primary care setting over 12 months. The goals of care coordination services through the CCMP fully support the goals of the Triple Aim of the Affordable Care Act (2010): improved health, improved health care, and improved cost value. Monthly telehealth coaching sessions were conducted by trained, certified medical assistants and supervised by a nurse practitioner. Outcomes to be evaluated at baseline, 6 and 12 months include the Chronic Disease Sample Questionnaire survey, and two clinical outcomes as appropriate to individual patients (HbA1c, blood pressure). Participant recruitment was completed in December 2015, with data collection scheduled for completion in December of 2016. Patients enrolled had a variety of chronic illnesses: 92% hypertension, 75% hyperlipidemia, 56% diabetes. Although the preliminary 3-month findings of the aggregated clinical outcomes lack statistical significance in all measures (e.g., no significant improvements found), these findings are noteworthy, as the ultimate goal is to prevent rapid deterioration in the elderly population. Once completed, the analyses will provide more understanding of CCMP effects on the overall health outcome for the iv Medicare beneficiaries with multiple chronic conditions. Primary care settings truly have great potential to improve the overall health outcomes of the chronically ill Medicare population. In particular, advanced practice nurses, with their advanced clinical skills based on evidence-based practice and workplace versatility, may play central roles in development, implementation, and evaluation of the CCMP in alignment with the Triple Aim