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Implementing Value-Based Care With Chronic Care Management (CCM)

What is Chronic Care Management (CCM)?


Chronic Care Management (CCM) is among the various care management programs provided by Medicare. As its name implies, CCM focuses on handling patients' two or more chronic conditions between regular office visits. The essence of the program lies in monthly clinical engagement and care planning.


To enroll a patient in CCM, they must give verbal or written consent. Additionally, they must have at least two chronic conditions anticipated to last for a year or more. As the healthcare provider, you must have noted these chronic issues at least 12 months before CCM enrollment. These conditions should pose a significant risk of death, acute decompensation, or decline. Moreover, you must provide at least 20 minutes of non-face-to-face service each month for Medicare reimbursement.


The services are delivered through remote interactions, including:

  • Monthly clinical review

  • Telephone calls

  • Physician reviews

  • Referrals

  • Prescription refills

  • Chart reviews

  • Scheduling appointments/services


These services are tailored to a patient's individual care plan, a comprehensive document detailing the patient's goals, health history, and behavior. It's collaboratively created with the patient post-CCM enrollment.


Medicare Part B covers 80% of this benefit for patients, with many secondary insurances covering the remainder. Providers and rural health clinics (RHC) can submit claims for this service using appropriate CPT codes that account for varying complexity levels. Reimbursement rates can vary by location.


3 Ways CCM Can Enable Value-Based Care Success


  1. Improve Patient Satisfaction and Engagement

Value-based care prioritizes creating a satisfying patient experience, aiming for transparent, valuable exchanges in healthcare, often perceived as complicated and costly. Engaging patients is crucial for better health outcomes, particularly in preventive care. CCM aids in encouraging this behavior.


Patients participating in CCM reported several benefits, including improved access to primary care teams and continuity of care, as per the Journal of General Internal Medicine. By enrolling in CCM, patients agree to monthly interactions with the care team or a care manager, expanding access to clinical staff. This increased engagement can enhance transparency and patient satisfaction, reducing the need for office visits.


2. Enable Better Patient Health

Chronic conditions can lead to severe health issues, but CCM participation can reduce hospitalizations and emergency room visits, according to a study by Mathematica Policy Research. Monthly check-ins and personalized care plans can help patients adhere to recommended therapies or interventions, improving overall health.


Continuous observation and management of chronic conditions, especially for patients with multiple conditions, can track changes in severity, providing valuable insight into their well-being. Additionally, CCM can complement other care management solutions, such as Behavioral Health Integration (BHI), for comprehensive treatment and personalized care.


3. Maximize Clinical Efficiency

CCM allows remote engagement and treatment of a high volume of patients, reducing reliance on office visits. With monthly engagement via phone or telehealth platforms, practices can support a continuum of care efficiently. Non-complex CCM tasks can be performed by staff, such as care managers, enabling engagement with numerous patients.


Software solutions can streamline CCM programs, automating tasks and integrating health data, increasing practice capacity and reducing staff workload. Outsourcing CCM programs is also an option, collaborating with external service providers to manage programs effectively, expanding services without additional staff resources.


Lastly, CCM reimbursements provide a new revenue source, supporting practice expansion or technology adoption to enhance efficiency further.


Offer Chronic Care Management To Your Patients With ChronicCare


ChronicCare partners with Physicians, Hospitals, Payors, and Employers to offer Chronic Care Management Services to their patients. We are dedicated to helping people improve their health and quality of life by maximizing their healthcare outcomes. We bridge the gap between healthcare visits, in order to ensure patients are continually cared for each month. 


Click here to connect with our team, we'd love to discuss potential benefits to your patients, staff, and practice.

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