Chronic care management at home in St. Louis.

What chronic care management is

A visit with a clinician lasts a short time. Diabetes, heart failure, lung disease and kidney disease go on every day in between. Chronic care management is the name for organized support during that in-between time: a written care plan, regular check-ins and one practice keeping track of the whole picture.

Medicare describes it as a service for people with two or more long-term conditions, and some other plans have similar programs. For people who have trouble getting to an office, chronic care management at home in St. Louis usually pairs phone check-ins with home visits from the treating practice.

What between-visit support looks like

The treating practice runs the program and decides what it includes. Most programs share a few features:

• A care plan that lists your conditions, medications, goals and the people on your care team
• Regular contact, often a monthly phone call
• Review of home readings such as blood sugar, blood pressure or weight
• Help with refills, test results and specialist appointments
• A way to reach the practice with a question between visits

It does not replace visits with a clinician. The guide to what patients should know about chronic care management explains consent and billing questions in more detail.

Who it tends to help

It is most useful for people who:

• Take many medications from more than one prescriber
• Have been in the hospital or emergency room recently
• Rely on a family member to keep track of appointments and readings
• Find it hard to leave home for office visits

It is voluntary. A practice asks for your agreement before enrolling you, and you can stop whenever you choose. Under Medicare’s rules one practice at a time provides it, so ask which practice would be in charge.

What a month of support can look like

Picture a person with diabetes, heart failure and a slow-healing foot wound. In the first weeks, the practice writes the care plan and checks the medication list against what is actually in the cabinet. After that, a staff member calls once a month, asks about weight, blood sugar, appetite and breathing, and notes anything new.

If the answers raise a question, the staff member passes it to the clinician, who decides what to do. That might mean a medication question, a lab order, an earlier visit or a call to the specialist. The practice records what was done so the next call starts where the last one ended.

Who may be involved

Care management is a team effort. A physician or nurse practitioner usually oversees the plan, and a nurse or care coordinator often makes the routine calls. A podiatrist (DPM) may be part of the team when diabetes affects the feet or a foot ulcer is present. The treating practice decides who does what, and you can ask who your main contact is.

How it connects to wound healing

Chronic wounds usually sit on top of chronic conditions. High blood sugar, fluid that builds up in the legs, and heart or kidney problems all affect how well skin repairs itself. Wound visits address the wound. Chronic care management watches the conditions underneath it.

The check-ins also catch problems that slow recovery before the next visit: a medication that ran out, swelling that came back, a poor appetite, a missed appointment. For someone receiving chronic wound care, Gateway makes sure the wound care clinician and that practice have the same information.

Home readings and remote monitoring

Some programs ask for a simple log of blood sugar, blood pressure or weight. Others use remote patient monitoring, where a device sends readings to the practice.

Ask the practice which readings it wants, how often, and what range should prompt a call. A medication review is a good companion to any program, since the care plan is only as accurate as the list behind it.

What Gateway arranges

Chronic care management is led by the treating practice. Gateway helps coordinate the work between visits:

1. If you have a primary care physician, we ask whether that practice offers chronic care management and keep it at the center of your care.
2. If you do not, we help connect you with a partner practice that provides primary care at home or in your facility.
3. We gather records and the current medication list so the practice starts with accurate information.
4. We keep wound care notes and primary care updates moving between the teams.

Coverage and any cost to you depend on the treating practice, your plan and the care needed. Our page on insurance questions lists what to ask before you enroll.

How it fits with your regular doctor

Chronic care management is meant to support the relationship you already have, not replace it. The practice running the program should be the one that sees you for your regular visits. If another clinician, such as a wound care clinician, makes changes, the program is how the primary care practice hears about it. Bring your care plan to every appointment, and ask for a new copy when something changes.

Medicare and other plan questions

In general terms, Medicare has a billing category for chronic care management, and it requires your consent. It is meant for people with two or more long-term conditions expected to last at least a year. A share of the cost may fall to you, and a supplemental plan may help with that. Medicare Advantage, Medicaid and commercial plans each have their own rules, so ask your plan and the practice before enrolling.

Primary care at home near you

Gateway helps connect people with Gateway clinicians in these and other communities. Availability is confirmed by location and care setting.

• Primary care at home in Chesterfield
• Primary care at home in University City
• Primary care at home in Webster Groves
• Primary care at home in Maryland Heights
• Primary care at home in South St. Louis
• Primary care at home in St. Peters
• Primary care at home in Wentzville
• Primary care at home in Imperial
• Primary care at home in Collinsville
• Primary care at home in Granite City

Changes to report between check-ins

Call the practice without waiting for the next check-in if you notice:

• Weight going up quickly over a few days, or new swelling in the legs or belly
• Blood sugar or blood pressure readings well outside your usual range
• More shortness of breath than normal, with activity or lying flat
• A new sore, or a wound that looks worse
• Dizziness, a fall or new confusion

Chronic care management is not an emergency service, and neither is Gateway. Call 911 for chest pain, severe trouble breathing, fainting or signs of a stroke.

How to start

Call 314-325-0126 or send the request care form with a name and phone number only. A family member can call for you. Have the names of your current doctors ready if you can, along with the pharmacy you use.

Family members doing much of this work can also read our caregiver support page.

Common questions

Related pages

• Primary care
• Chronic care management for patients
• Remote patient monitoring
• Medication review
• Chronic wound care
• Caregiver support
• Transitional care after discharge
• Annual wellness visits