Living with multiple chronic conditions?

    Speaking even briefly with Janet Mitchell about her new role as Chronic Care Management nurse at Melissa Memorial Hospital quickly reveals her passion for patient care — especially those with multiple chronic conditions and complex care plans.
    A problem many hospitals face is that such patients frequently end up in the emergency room or hospitalized for things that never should have gotten to that point. Both Medicare and MMH recognized the issue, leading to the development of the local CCM program. With the groundwork laid, Mitchell was hired and, on Oct. 1, saw her first patient as a CCM nurse. In the past, she spent three years as a staff nurse at MMH and remained as a per diem nurse there even while working elsewhere.
    Presently, the Melissa Memorial CCM program is just for Medicare patients, and there are five signed up so far. The goal is to serve as many people as needed, and hospital employees are aware that there could be a future need to branch out to include Medicaid and private insurance patients as well.
    
Who is CCM for?
    There’s a wide range of chronic conditions, which are long-term and may not have a cure. Think diabetes, chronic obstructive pulmonary disease, congestive heart failure, asthma, high blood pressure, cancer. The list goes on, and Mitchell explained that Medicare hasn’t set strict limitations about which conditions qualify a patient for CCM, so she expects a variety of patients could benefit from the new program.
    According to the Centers for Disease Control and Prevention, six in 10 U.S. adults have a chronic disease. Four in 10 have two or more. It’s those people who have multiple comorbid conditions that are eligible for CCM.
    Consider someone recently diagnosed with coronary artery disease and high blood pressure. They may not understand the ramifications of their diseases yet and likely have several new medications and specialists to see.
    If that person enrolls in CCM, Mitchell will serve as their go-to person to oversee care. She can help make sure follow-up appointments are scheduled and completed. She can help the patient understand their medications — especially when changes are made. She can coordinate preventative care and various health screenings relevant to the specific patient’s conditions.
    While a patient might be seeing many different providers and specialists, Mitchell is a source of consistency throughout that process. In addition to being a liaison between patients and providers, Mitchell also acts as a sort of health coach. When coming up with a care plan, she explained, she wants patients to take ownership of their treatment, setting their own goals. With those goals in mind, Mitchell can help them find resources in the community to meet them.
    She also coaches patients on looking for subtle changes in themselves. If she can teach them to be aware of signs that a problem is brewing — perhaps a change in medication is needed — adjustments can be made before a small problem escalates into something that could potentially land a patient in the ER.
    Think back to that patient with coronary artery disease and high blood pressure. By making lifestyle changes and staying on top of treatments, the goal of CCM is to prevent a future stroke or heart attack in that person.
    On top of everything else offered through the CCM program, those enrolled have 24/7 emergency phone access to a health care professional who knows their case and can answer questions that might arise. Even outside of those emergency calls, Mitchell has face-to-face visits and phone calls to regularly check up on her patients. So far, she said, she’s had considerable contact with the five patients who are enrolled in the program.