What Is Chronic Care Management?
Elisabeth 
What exactly is Chronic Care Management (CCM) and why should primary care providers consider implementing it?
Chronic Care Management (CCM) refers to a structured approach to ensuring comprehensive care for individuals with chronic health conditions. According to research by the Centers for Disease Control & Prevention (CDC), nearly 60% of adults in the United States live with at least one chronic condition, and complications of chronic disease result in high costs, emphasizing the critical need for efficient management strategies. Data from the Centers for Medicare and Medicaid Services (CMS) and the CDC further supports the efficacy of CCM programs in improving patients’ quality of life and reducing hospital admissions.
A Brief Overview of CCM:
CCM is a program created by the Centers for Medicare and Medicaid Services (CMS) and is designed to help primary care providers transition to value-based care.
CCM focuses on proactively improving patient outcomes for patients with chronic conditions, which can lead to better reimbursement rates for clinics and cost-savings for patients, taxpayers, and the entire healthcare system.
CCM allows providers to bill for non-face-to-face care management services that are provided to eligible patients, therefore increasing revenue and promoting sustainability for primary and specialty care practices.
CCM focuses on structured health-related follow-up, patient engagement, and connected care.
Examples of CCM Services:
Ensuring regular, structured “touch points” with eligible patients between clinic visits: phone calls, patient portal messages, etc. Regular check-ins foster a sense of trust and ensure that patients remain engaged in self-care.
Providing care coordination and collaboration with the multi-disciplinary team, including the patient, physicians, nurses, therapists, pharmacists, caregivers, social workers, community health workers, and specialists. An effective CCM program ensures that patients don’t get “lost” in the complex healthcare system.
Developing a provider-approved and patient-focused care plan and promoting adherence to the care plan through goal setting and patient education. CCM nurses guide patients in realistic goal-setting and ensure that patients have the resources needed to successfully meet their health goals.
Tracking patient progress meticulously and addressing changes in patient status promptly, therefore minimizing complications of chronic disease.
Increasing access to care through multiple channels of communication (24/7 access, patient portal access, personal nurse access, etc.).
As healthcare evolves, the role of Chronic Care Management becomes increasingly important, and its reimbursement by Medicare for over a decade is a testament to the power of integrated care strategies, including compassionate support and interpersonal connections that are vital for holistic patient care.
Does your clinical practice have a CCM program? If not, why not?
Chronic Care Management enhances patient care and helps practices remain sustainable. At MedAlign Innovative Solutions, we believe that Chronic Care Management is most effectively done by nurses. We partner with primary and specialty care clinics to implement and operate care management programs. We will help you start and scale your CCM program. Schedule a complimentary consultation to see if your practice is ready to implement CCM today!
References:
Benavidez GA, Zahnd WE, Hung P, Eberth JM. Chronic Disease Prevalence in the US: Sociodemographic and Geographic Variations by Zip Code Tabulation Area. Prev Chronic Dis 2024;21:230267. DOI: http://dx.doi.org/10.5888/pcd21.230267
Categories: : Chronic Care Management, Primary Care
