USA DNA TESTTM

CHRONIC CARE MANAGEMENT
​(CCM)
CHRONIC CARE MANAGEMENT (CCM)
As of January 1, 2015, the Centers for Medicare and Medicaid Services (CMS) recognizes care management as a critical component of primary care that contributes to better health outcomes and care for individuals, as well as reduced spending. 

Chronic Care Management (CCM) is defined as patients having:

  • Two or more chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions that place the patient at significant risk of death, or acute exacerbation/decompensation
THE CARE PLAN
Comprehensive problem list including expected outcome and prognosis with measureable treatment goals
Symptom management and planned interventions
Accessible community and social services
Plan for care coordination among all providers
Medication management, including current medication list, allergies, reconciliation, and oversight of patient self-management
Designated person responsible for each intervention
Any requirements for regular review/revision