Earlier this year the Centers for Medicare and Medicaid Services (CMS) unveiled Comprehensive Primary Care Plus (CPC+) in an effort to strengthen primary care services through a regionally-based multi-payer payment reform and care delivery transformation. CPC+ is a new advanced primary care model. Set to begin in January 2017, CPC+ will reward quality and value through modified payment structure supporting primary care.
Patients managing chronic and complex conditions are often also trying to control chronic pain. Proper pain monitoring and routine medication review can prevent abuse of drugs, particularly opioids, alcohol or other substances. Care coordination entails instruction for appropriate use of pain medications, timely scheduling of appointments, ensuring prescription refills, and important preventive health reminders. It also includes providing chronic care patients with the right pharmacological and psychological treatment options and information for effective self-care.
Moving a patient from a hospital to their home or care facility in a community setting is a delicate process. Patients, family members or caregivers can receive confusing recommendations, a laundry list of medications, and conflicting instructions regarding follow-up care. If they are not included in planning or provided with clear “next steps” there can be significant gaps in post-discharge care. As a result, patients will most likely return to the hospital, and often times with more complications than before.
Social conditions and chronic disease are related. Overcoming social factors can be a challenge for the two-thirds of Medicare beneficiaries with two or more chronic conditions. Many of these patients struggle with housing concerns, lack of access to transportation, inadequate nutrition, and job loss. Some are isolated from family and face fragmented care.
You may ask yourself—Is it possible for me to help my senior patients quit smoking? After years of addiction and attempts can they really overcome the challenges? The answer is YES! In fact, eliminating harmful tobacco use is essential to chronic care management. There are so many ways to help your patients quit. Yes, smoking cessation can be an uphill battle, but your patients don’t have to fight it alone. Changing deeply engrained behavioral habits and addictions can be more difficult for older patients. However, these patients may be more responsive to reminders of more personal reasons to quit. For example, grandchildren, children, spouse, friends or simply feeling better themselves.