Why hospital administrators should care about chronic care management

By 2030, about one in five Americans will be older than 65. As they age and life expectancy increases, the number of individuals with chronic health conditions, and demand for health professionals to care for them, will grow.

Currently, three in four Americans over the age of 65 have two or more chronic health conditions, such as hypertension, cancer, stroke, arthritis and diabetes. These patients also account for 83.1 percent of all prescriptions in the United States.

Care for patients with multiple chronic conditions is not just an issue for patients and primary care physicians. Hospitals care for many people with chronic care needs. So too do the oncologists, cardiologists, neurologists and other specialists who treat them in and outside the hospital setting. In many cases, patients end up at the hospital or with the specialist because of gaps in care in the primary care setting.

My organization, the Gerontological Advanced Practice Nurses Association, represents more than 3,700 advanced practice nurses that work with the aging population. We advocate for quality care for older adults, collaboration with healthcare providers, and education for consumers regarding issues of aging.

In recent years, I’ve seen different care models emerge to provide support to patients with complex care needs, such as the elderly. One of the most promising, is chronic care management (CCM), which involves facilitating care in-between physician office visits for patients on Medicare with multiple chronic conditions. Care coordination between physician office visits can help individuals follow their care plan, adhere to their medication regimen, and keep doctor appointments. It can also help identify and pre-empt issues with potential to turn into health tragedies. Yet, despite government reimbursement for providers (and modest copays for patients), CCM adoption by clinicians and patients is low.

Too few primary care physicians take advantage of this program, and the impact spills over to hospitals. Many older patients, who, with some help, could have better managed their high blood pressure, diabetes or kidney disease, are rushed to the hospital where they receive triage care, only to return weeks later with the same symptoms.

I believe the key to making CCM services readily available is to educate more primary care physicians (PCPs) about its benefits, including the fact that they can be reimbursed by Medicare. Hospitals can also provide information about CCM services to patients as they are being discharged, and share information with the PCPs who are on rotation at their hospitals, so they can provide information in their general practices.

Once PCPs learn more, they are open to using chronic care management services with patients. According to a recent survey by Quest Diagnostics, which provides CCM in addition to its core diagnostic services, almost nine in ten PCPs (87%) say they would use this type of service to monitor their patients with chronic conditions by setting up a monthly call with a nurse or nurse care coordinator. The same survey also found that a majority of patients would take advantage of a CMS-reimbursed CCM service.

In the U.S., more than 74 million Baby Boomers are retired or soon-to-be retired. It is all but certain there will be greater need for chronic care health services. Hospitals should not be the first line of defense to manage the sheer number of elderly patients and their chronic care conditions. Instead, if PCPs adopt a chronic care services approach, hospitals will then be able to focus on specialized medical and nursing care. After all, if the goal is to reduce hospital visits, then the approach should focus on care that helps patients maintain their quality of life in a non-hospital environment for as long as possible.


Katherine A. Evans is a family and geriatric nurse practitioner certified in hospice and palliative care and is the recent past national president of the Gerontological Advanced Practice Nurses Association (GAPNA).

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