Chronic Care Management (CCM)

What is Chronic Care Management?

Chronic Care Management (CCM) is a comprehensive approach to manage chronic diseases such as diabetes, hypertension, COPD, and other common chronic conditions. CCM is a patient-centered, team-based model that focuses on coordinating care, improving health outcomes, and enhancing the quality of life for individuals with chronic conditions.

If the patient is enrolled in Medicare or Medicaid and has had two or more chronic conditions for the past 12 Months, Medicare offers CCM services to help the patient manage their chronic conditions.

Key Components of CCM:

Assessment and Care Planning:

Identifying patient needs, creating personalized care plans, and setting goals.

Coordination of Care:

Connecting patients with their care team (Providers and Clinicians)

Monitoring and Support:

Using methods such as regular check-ins and education about lifestyle changes to manage the chronic conditions of patients.

Medication Management:

Optimizing medication regimens and monitoring patient adherence to their prescriptions.

Patient Engagement:

Empowering patients to take an active role in their care.

Benefits of CCM:

Increased Efficiency:

Streamlined care processes and reduced administrative burdens.

Reduced Healthcare Costs:

Proper management and preventative care reduces unnecessary tests, procedures, and hospitalizations.

Improved Health Outcomes:

Better management of chronic conditions leads to lower rates of complications and hospitalizations and boosts a patient’s quality of life.

Enhanced Patient Experience:

Personalized care, increased engagement, and improved communication between the patient and their care team.

Which Patients Can Benefit from CCM?

Patients with two or more chronic conditions
Patient with complex medication regimens
Individuals with cognitive or functional impairments
Patients with high healthcare utilization

Chronic Care Management is a vital approach to address the growing burden of chronic diseases. By providing comprehensive coordinated care, CCM reduces healthcare costs, enhances patient experiences, and improves health outcomes.

FAQ

CCM services include care planning, coordination, and monitoring.

Patients must agree to participate and give either verbal or written consent.

The clinician team has to contact each patient at least once a month either on the phone or in person.

Although reimbursements can vary, on average, you can expect a reimbursement of approximately $62/patient each month.

You need to check with the patient’s insurance plan to provide CCM services.

Physicians and certain Non-Physician Practitioners (Nurse Practitioners, Physician Assistants, Clinical Nurse Specialists, and Certified Nurse Midwives)
Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC)
Hospitals, including Critical Access Hospitals