Clinicians and healthcare policymakers are accepting that physical and mental health are closely interconnected. This view is now influencing the aims and focus of value-based care through Chronic Care Management, care coordination, and Integrated Behavioral Health.

Annual Wellness Visits (AWV) for Medicare beneficiaries can add measurable value to benefit patient health outcomes, quality performance, and service revenue. However, it’s critical to optimize physician and staff time with a reliable, standards-based, and streamlined workflow.

Many physicians and clinicians pride themselves on the relationships they develop with their patients. By creating a patient-centered care plan, providers can enhance engagement, deliver timely interventions, align on outcome goals, and improve care team coordination.

This year brings significant opportunities and changes to care management that invite providers, health plans, and care management service organizations to transform. Central to these changes is the launch of the Advanced Primary Care Management program.

Providers implementing Annual Wellness Visits or quality improvement initiatives identify and hone best practices that meet their unique patient and practice needs. When operationalized, these standards achieve four goals:

The Centers for Medicare & Medicaid Services (CMS) launched the Guiding an Improved Dementia Experience (GUIDE) Model on July 1, 2024. Running from 2024 through 2032, this program is one of the first Innovation Center care models to focus on longitudinal, condition-specific comprehensive care.

Medicare’s Chronic Care Management (CCM) program supports patients in managing multiple chronic conditions, slowing disease progression, preventing costly care, and enhancing quality of life. Nurses play a crucial role in this program, particularly for high-risk, vulnerable populations.

Chronic Obstructive Pulmonary Disease (COPD) is the fourth leading cause of death in the US, killing more than 150,000 people each year. COPD is a progressive and incurable lung disease experienced in two primary forms: chronic bronchitis and emphysema.

More than 60% of older Americans receive help from unpaid caregivers; typically, these include family, friends, or neighbors. Engaging family as part of the patient’s overall care team has been shown to improve chronic disease management, including:

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