August 1, 2024

Comprehensive Care Management Program: Supporting Patients with Chronic Illnesses

Primary Care
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When addressing chronic conditions, many healthcare professionals follow a chronic care management (CCM) program. At Fort HealthCare, the focus is more on a comprehensive care management program. This slight change in the name has a significant impact on patient outcomes, because providers are really taking the whole person into account.

Erin Sterwald, BSN, RN and Sam Fuller, BSN, RN, run and are very integral in promoting the CCM program at Fort HealthCare. Here, they share more information about the program and why it leads to better outcomes.

Developing a Personalized Care Plan

Each patient receives a personalized care plan that allows Sterwald and Fuller to do a deeper dive into what outside factors might be contributing to their health concerns. For example, they ask questions like:

  • Is their medication to expensive?
  • Can they get around the house safely?
  • Do they have the appropriate resources in the home to help with activities such as bathing, preparing meals, going grocery shopping?
  • Do they have rides to their medical appointments?
  • Who acts as their social support system?

“We identify their needs and help connect patients to community resources we have and that are really readily available for them,” states Sterwald. “And, we can help guide patients with education. We provide them ways to help self-manage their illnesses at home. We do frequent check-ins to monitor how their health status is with the implementations they’ve been doing.”

Who Is a Good Candidate for the CCM Program?

The definition of a chronic condition is an illness that is expected to last for at least 12 months and cause a decline in the patient’s health. Some examples of chronic conditions might include hypertension, diabetes, depression, heart failure, kidney disease, and chronic obstructive pulmonary disease (COPD).

Any patient with a Fort HealthCare primary care provider who has been diagnosed with one or more chronic illnesses is eligible to enroll in the program. All the patient needs to enroll is for their primary care provider to contact the CCM department.

“Our role as CCM nurses is to work alongside the patients and their caregivers to coordinate care with their primary care providers, as well as with the specialists they might see on a routine basis. We advocate for patients, educate them regarding their illnesses, and collaborate with the entire care team. The CCM team is available for patients to help as little or as much as they would prefer,” assures Fuller.

This focus on coordination really solidifies the effectiveness of the CCM program. “We see a lot of patients who have multiple specialists that are managing their care. We make that connection between all their providers so they can have that continuity of care, and we ensure everybody is on the same page with what’s going on,” notes Sterwald.

Benefits of the CCM Program

Fuller and Sterwald have witnessed several benefits among patients enrolled in the CCM program. For instance, improved quality of life, reduced stress, a stronger connection to one’s care team, and reduced hospitalizations and emergency department visits.

“With our support from CCM, patients are more likely to achieve their health goals. Regular interactions and personalized attention help patients stay connected and engaged in their healthcare. This leads to patients taking a proactive approach to health,” shares Sterwald. “We find that patients are truly wanting to be on top of things, getting their preventative care services taken care of. And, by managing these chronic conditions more effectively, it really does allow patients to experience better outcomes.”