Establishment of Outpatient Rounds by an Interprofessional Chronic Care Management Team

Chronic conditions are collectively the leading cause of death in the United States, and nearly half of all Americans have 2 or more chronic conditions.1 In 2015, the Centers for Medicare and Medicaid Services implemented chronic care management (CCM) reimbursement strategies to reduce the burden of chronic conditions on the U.S. healthcare system. Patients eligible for CCM services have 2 or more chronic conditions expected to last more than 1 year (or until death) and are at significant risk for death or decline.(2) In the CCM model, patient-specific care plans are established and revised, and the plans include measurable treatment goals that focus heavily on medication management, community resources, functional needs, and transitional care services.3