Chronic Care Management (CCM) and RPM: Enhancing Value-Based Care

Chronic care management is a holistic approach to maintaining chronic conditions in patients, which has received an upgrade in recent years as coordinating care between various healthcare professionals became easier.

The remote patient monitoring market, which is set to reach $175.2 billion by 2027, promises an exciting overlap in which remote patient monitoring and chronic care management can utilize technology for better results in managing chronic conditions.

This article overviews key differences between remote patient monitoring and chronic care management, as well as the ways CCM and RPM work together. We use the holistic perspectives of the healthcare industry and outsourcing IT team to give you the best insights on the topic.

Chronic care management: The basics

Chronic care management refers to the comprehensive care coordination and management services provided to patients with chronic diseases. Provided by healthcare professionals, these services are aimed at improving patient outcomes and improving the personal engagement of patients. Components of chronic care management include:

• Coordinated care between multiple providers
• Educating patients about their condition
• Medication management

Chronic care management is crucial for the healthcare sphere because of how many people are affected by chronic disease. Here are some interesting facts about chronic care management:

• The Centers for Disease Control and Prevention (CDC) estimates that six in ten adults in the United States have a chronic disease, and four in ten adults have two or more (Source ).
• Chronic diseases are extremely costly – they account for approximately 90% of the US $3.8 trillion in annual healthcare costs, according to the CDC (Source ).
• What is more, non-adherence is a big problem in chronic care management – up to 50% of medications for chronic diseases are not taken as prescribed (Source ).
• Chronic diseases are a worldwide critical issue, as WHO estimates that 74% of all deaths worldwide are due to chronic diseases, many of which are preventable with effective chronic care management (Source ).

Key differences between chronic care management and remote patient monitoring

Chronic care management and remote patient monitoring are both helpful for patients with chronic conditions and are aimed at managing patients' health more effectively. CCM and RPM both assist in lowering patient care costs.

However, there are also a lot of differences between remote patient monitoring and chronic care management. Here are the key RPM vs. CCM differences:

1. CCM focuses on providing comprehensive care coordination for patients with multiple chronic conditions. This involves creating a patient-centered care plan, coordinating with other healthcare providers, and supporting patients in managing their health. RPM uses digital technologies to collect medical and other forms of health data from patients remotely.
2. The key component of CCM is care coordination, while RPM is all about real-time monitoring.
3. One key difference between CCM and RPM is that CCM requires 24/7 access to care, while RPM does not.
4. RPM involves interpreting the data received by devices and cooperation with the patient on the treatment plan. CCM consists of creating a comprehensive care plan, personal needs assessment, preventive care services, medication analysis, self-management oversight, and care coordination.
5. RPM vs. CCM have different CPT codes. CCM has additional codes for more complex cases, but RPM CPT codes do not involve that.
6. The financial difference between ccm and rpm is that the minimum monthly reimbursement of RPM is more expensive than CCM's.
7. CCM services can be provided by healthcare professionals in various settings, including primary care practices, hospitals, or home health agencies. RPM is typically facilitated through digital health technologies.
8. RPM is not always meant for chronic disease management - it can also be used for acute care, rehabilitation, or general health management for people without chronic or acute diseases.

The benefits of RPM in chronic care management

Differences aside, remote patient monitoring for chronic disease management is beneficial in many ways. Here are some key ways it can help:

• Improve patient engagement: By tracking their health metrics, patients often better understand their condition and the impact of their behaviors, leading to better self-management.
• Enhance care coordination: With continuous health data, communication between healthcare providers involved in patient care can be more efficient and effective. This data provides a common ground for discussing the patient's health status and treatment plans.
• Reduce hospital readmissions and enable early detection of complications: With RPM, healthcare providers can proactively manage a patient's health condition and intervene promptly if any alarming changes are detected. This can prevent the need for emergency care or hospital readmission. RPM devices can track trends in health data over time, which can help identify subtle changes or patterns that may suggest a developing complication.

How CCM and RPM can work together

All things concerned, the best strategy for healthcare providers to tackle chronic diseases is by combining CCM and RPM. Here are some of the ways RPM and CCM work perfectly together:

• Clinical complementarity: CCM provides a structured framework for managing patients with multiple chronic conditions. RPM enhances this framework with real-time data about patient health.
• Financial synergy: Both RPM and CCM are recognized by Medicare in the United States. When used together, they could reduce the overall cost of healthcare by preventing avoidable hospitalizations and emergency room visits. Chronic care management and RPM can be billed together, which saves healthcare costs for the patient.
• More frequent monitoring: While CCM involves regular patient-provider interactions, RPM takes this further by continuously monitoring patients' health status. This allows for more frequent adjustments to the care plan as needed, improving the management of the patient's condition.
• Personalized and responsive care: The individual health data provided by RPM can be used to personalize the care plan developed in CCM. Providers can adjust treatments based on patients' unique patterns and responses rather than relying solely on less frequent clinical measurements.
• Closing gaps in care: Data from RPM can be shared between all healthcare professionals on the patient team, which helps to close care gaps. 24/7 access to healthcare providers guaranteed by CCM and 24/7 health data monitoring provided by RPM offer as much monitoring as any patient needs.

The integration of RPM and CCM

Smooth integration of RPM/CCM requires a consistent effort from the healthcare team to put everything in place. The team should start with a comprehensive assessment of the patient's health status. As a part of this assessment, they should determine which RPM could support the management of the patient's conditions (f.e., blood pressure monitor for a patient with hypertension or a glucose meter for a patient with diabetes).

Once RPM is implemented, it gives the team access to monitor the patient's health data continuously. Based on this data, they can adjust the CCM strategy. Moreover, the care team can use the data from the RPM to communicate with the patient about their health status and discuss concerns. When billing for RPM/CCM together, the team should ensure they meet the time requirements for each service.

Binariks experts for your RPM and CCM

To sum up, chronic care management and RPM are the perfect team for controlling chronic conditions and educating and empowering patients on their journey through self-management. It is possible to turn remote patient monitoring for chronic disease management and CCM into one viable solution.

Outsourcing IT teams with experience in complex solutions for healthcare organizations like Binariks can greatly assist healthcare providers in medical RPM CCM integration. Here are some of the ways we can help:

• Provide technical guidance to integrating RPM devices and implementing CCM software according to the healthcare provider's unique needs.
• Ensure integration with existing healthcare systems, such as Electronic Health Records (EHRs) or other platforms or software used in your healthcare organization.
• Customize medical RPM CCM systems to suit the goals of a healthcare provider.
• Assist in training to the healthcare staff on how to use RPM or CCM effectively.
• Help maintain software, troubleshoot issues, and update the system as necessary.
• IT teams can develop secure platforms for data sharing between healthcare providers for better-coordinated care.

We would also like to invite you to learn more about RPM on our blog. For example, just recently we did a detailed review of remote patient monitoring companies .