The ultimate guide to chronic care management

Chronic Care Management: The Ultimate Guide

In an era where chronic diseases are becoming increasingly prevalent and complex, the need for comprehensive and effective chronic care management has never been greater. Chronic conditions, such as diabetes, heart disease, and arthritis, can significantly impact an individual’s quality of life and pose substantial challenges to healthcare providers in managing the patient’s care. And given that patients are only seen by their provider in the office a few times per year, managing patients in between office visits has become essential to improving outcomes and lowering costs with chronic disease patients. Recognizing this, healthcare systems and professionals are embracing the concept of chronic care management to provide proactive and personalized care to patients with ongoing health issues. This article serves as the ultimate guide to chronic care management, delving into its definition, goals, key components, benefits, and strategies for successful implementation. Whether you are a healthcare professional, a patient, or someone seeking to understand the intricacies of managing chronic conditions, this guide aims to equip you with the knowledge and tools necessary to navigate the complexities of chronic care management effectively.

Contents In This Guide:

What is Chronic Care Management?

What is Chronic Care Management to Patients?

What is the Goal of Chronic Care Management?

Is Chronic Care Management Worth It For Healthcare Providers?

What Diagnoses Qualifies for CCM?

What Reimbursements Are Available for CCM Services

How to Enroll Patients in CCM?

What is Chronic Care Management (CCM)?

Chronic care management (CCM) is a remote care program designed to provide comprehensive and coordinated care for individuals living with multiple chronic conditions and comorbidities. It is a proactive and patient-centered strategy that focuses on improving outcomes, quality of life, and lowering costs for patients in the program. Unlike traditional episodic care, where healthcare providers primarily address acute symptoms or immediate health concerns, chronic care management takes a holistic and long-term perspective for some of the most serious health conditions.

At its core, chronic care management recognizes that chronic diseases are often complex and multifaceted, requiring ongoing monitoring, treatment, and support. These conditions typically persist for an extended period and may require primary care  interventions related to both medical & social determinants of health (SDOH), as well as a combination of lifestyle modifications, community resources, and patient education. Chronic care management aims to bridge the gap between healthcare visits and empower patients to actively engage in their own care.

Key Elements of Chronic Care Management:

Care Coordination:
One of the fundamental aspects of chronic care management is the coordination of healthcare services across multiple providers and settings. This includes primary care physicians, specialists, nurses, pharmacists, caregivers & family members, and other healthcare professionals involved in the patient’s care. Proper and timely care coordination ensures that information flows smoothly, treatments are aligned, and the patient receives consistent and cohesive care.

Personalized Care Plans:
Chronic care management emphasizes the development of personalized care plans tailored to each patient’s unique needs and circumstances. CCM care plans are living documents, routinely updated, that outline specific goals, treatment strategies, and self-management techniques to address the individual’s chronic condition effectively. They take into account factors such as the patient’s medical history, physician’s notes, SDOH needs, lifestyle, preferences, and social support network.

Regular Monitoring and Follow-up:
CCM involves regular monitoring and follow-up to track the patient’s progress, adjust treatments as necessary, and deliver timely primary care interventions. This may include scheduling office & same-day sick visits, facilitating completion of annual wellness goals, performing required assessments, medication reconciliation, telehealth consultations, remote monitoring technologies, and frequent communication between the patient and their healthcare team. Continuous monitoring helps detect changes in the patient’s health status, enabling timely interventions and proactive management.

Patient Education and Self-Management:
Empowering patients with knowledge and skills to manage their chronic conditions is a crucial component of chronic care management. Education on topics such as medication management, symptom recognition, healthy lifestyle choices, and coping strategies equips patients with the tools to actively participate in their care. By promoting self-management, chronic care management aims to enhance patient engagement, improve treatment adherence, and foster a sense of control over their health.

Engagement of Providers & Practice Staff:
Effective Chronic Care Management relies on the active engagement of healthcare providers and practice staff. They collaborate seamlessly to deliver patient-centered care, receive specialized training, ensure efficient communication, and embrace technology for improved patient outcomes. This engagement enhances care coordination and strengthens the overall CCM process.

In the next section of this guide, we will delve deeper into the patient side of things.

What is Chronic Care Management to Patients?

To patients, when CCM is implemented properly, enrolling in a chronic care management program means access to a dedicated nurse, connected directly to their primary care physician, providing personalized care on a monthly basis to help them better manage their conditions in between office visits to avoid ending up in the ED. It recognizes that living with a chronic disease can significantly impact their daily lives, and CCM aims to support them in becoming more engaged in their own healthcare, but without having to leave the comfort of their own home.

CCM engages patients longitudinally with a structured and coordinated system of care that addresses not only the immediate symptoms but also the long-term management of their condition. To be successful, remote CCM nurses must work  collaboratively with the patient’s care team to develop personalized care plans that take into account the patient’s medical history, social determinant needs, lifestyle, preferences, and goals.

One of the primary benefits of CCM for patients is the emphasis on proactive management and self-care. They are empowered with the knowledge and tools to better understand their condition, make informed decisions, and actively participate in their own care. Patient education plays a vital role in CCM, covering topics such as medication management, healthy lifestyle choices, symptom recognition, and how to accurately take your vitals (especially when remote monitoring is implemented).

Overall, patients enrolled in a CCM program feel more connected to their primary care physician, are more empowered to better manage their chronic conditions, receive earlier primary care interventions and have a reduced risk of ED visits and/or hospitalizations.

What is the Goal of Chronic Care Management?

The primary goal of chronic care management is to improve patient quality, improve patient experience and lower total cost of care for patients living with multiple chronic conditions and comorbidities. It aims to achieve this by providing comprehensive, coordinated, and patient-centered care that goes beyond simply treating acute symptoms or immediate health concerns. The overarching objectives of CCM include:

  1. Improved Health Outcomes & Lower Total Cost of Care:
    The #1 goal of every CCM program is always to have a positive impact on outcomes for patients, which ultimately also leads to lower overall cost of care. This involves managing their symptoms effectively, preventing disease progression, minimizing complications, and increasing overall frequency of primary care touchpoints with the patient.. By implementing evidence-based practices, regular monitoring, and proactive interventions, CCM will improve outcomes & experiences and lower costs across the enrolled population. 

  2. Enhanced Patient Engagement:
    Engagement leads to improved outcomes in healthcare. As such, a successful CCM program should place  a strong emphasis on patient engagement and empowerment. While the goal is to actively involve patients in their own care, ensuring that they have a voice in treatment decisions, understand their condition and treatment options, and are equipped with the knowledge and skills to manage their health effectively, to foster engagement, the patient must get value out of the program. This means connecting with them, forming a relationship and providing them with access and resources they would not otherwise get through a standard office visit. Engaged patients are more likely to adhere to treatment plans, make healthy lifestyle choices, and actively participate in their healthcare, leading to improved outcomes.

  3. Care Coordination and Continuity:
    Another vital goal of CCM is to improve care coordination and continuity across different healthcare providers and settings. Many individuals with chronic conditions require care from multiple specialists and healthcare professionals, and CCM aims to ensure that information is shared seamlessly, treatments are coordinated, and there is a consistent approach to managing the patient’s health. This helps avoid fragmented care, reduces unnecessary duplication of services, and promotes a more holistic and efficient healthcare experience.

  4. Preventive and Proactive Care:
    CCM emphasizes the importance of preventive and proactive care. Rather than solely focusing on managing acute episodes or exacerbations, CCM aims to anticipate and prevent complications associated with chronic conditions. This involves regular monitoring, early detection of changes in the patient’s health status, and timely interventions to prevent or mitigate adverse events. By taking a proactive approach, a successful CCM program will reduce hospitalizations, emergency room visits, and other avoidable healthcare utilization.

  5. Improved Patient Satisfaction:
    Ultimately, when patients enrolled in CCM experience better outcomes, increased access and feel more connected & supported by their primary care physician, both satisfaction and loyalty improve significantly. By providing comprehensive and personalized care that addresses their individual needs, preferences, and goals, CCM enhances the patient-provider relationship and fosters a sense of trust and partnership. Patients who feel heard, understood, and supported in managing their chronic conditions are more likely to be satisfied with their care and experience a higher quality of life.

In summary, the overarching goal of chronic care management is to optimize the well-being of individuals with chronic conditions through improved health outcomes, enhanced patient engagement, coordinated care, preventive strategies, and increased patient satisfaction. By taking a proactive and comprehensive approach to managing chronic diseases, CCM aims to transform the healthcare experience for both patients and providers.

Is Chronic Care Management Worth It for Healthcare Providers?

Yes, when implemented correctly, a chronic care management program is always worth it for both patients and healthcare providers. Here are some reasons why a CCM program can be invaluable to health systems & providers:

  1. Improved Population Health Management:
    CCM is instrumental in managing chronic conditions at a population level and has been shown to lead to better health outcomes for patients with chronic conditions. By implementing CCM strategies, healthcare providers can more easily identify and manage high-risk patients, target interventions effectively, and improve health outcomes across a larger patient population. This population health management approach helps address the growing burden of chronic diseases and improves the overall health of communities. Studies have indicated that CCM interventions result in reduced hospitalizations, emergency room visits, and disease progression, leading to improved quality of life for patients.

  2. Cost Savings:
    Due to existing reimbursements for CCM services, CCM programs can be implemented with minimal upfront costs, are sustainable long-term and will lead to cost savings & improved value-based performance when implemented correctly. By focusing on preventive and proactive care, CCM helps avoid costly hospitalizations and emergency room visits that often occur when chronic conditions are not adequately managed.

  3. Enhanced Patient Engagement:
    CCM places a strong emphasis on patient engagement and self-management. By empowering patients with knowledge, skills, and support, CCM encourages them to actively participate in their own care. Engaged patients are more likely to adhere to treatment plans, make lifestyle modifications, and seek timely healthcare, resulting in better health outcomes and satisfaction with their care.

  4. Care Coordination and Continuity:
    For patients with chronic conditions, CCM ensures that care is well-coordinated and consistent across different healthcare providers and settings. This helps prevent fragmented care, reduces unnecessary duplication of services, and promotes better communication and information sharing. Care coordination improves patient safety, reduces medical errors, and enhances the overall healthcare experience.

  5. Patient Satisfaction:
    CCM focuses on meeting the individual needs, preferences, and goals of patients. By providing personalized care plans, regular monitoring, and ongoing support, CCM enhances patient satisfaction. Patients feel more involved in their healthcare decisions, have better access to their healthcare team, and experience a higher level of care coordination. Increased patient satisfaction leads to improved patient-provider relationships and better overall healthcare experiences.

Chronic care management is worth it due to its positive impact on health outcomes, cost savings, enhanced patient engagement, improved care coordination, increased patient satisfaction, and effective population health management. By investing in CCM, healthcare systems and providers can deliver more comprehensive and patient-centered care, resulting in better overall outcomes for individuals living with chronic conditions.

What Diagnoses Qualify for Chronic Care Management?

Chronic care management is designed to support individuals with two or more chronic conditions that require ongoing management. On average, 75% of Medicare patients will meet this criteria. And while specific diagnoses can vary slightly depending on healthcare settings and guidelines, the following are common examples of conditions that qualify for CCM:

  • Diabetes:
    Both type 1 and type 2 diabetes are commonly included in CCM programs. These conditions require ongoing monitoring of blood sugar levels, medication management, lifestyle modifications, and preventive care to prevent complications.

  • Hypertension (High Blood Pressure):
    High blood pressure is a chronic condition that often requires long-term management. CCM can help individuals with hypertension monitor their blood pressure regularly, adjust medications as needed, and make lifestyle changes to maintain healthy blood pressure levels.

  • Congestive Heart Failure (CHF):
    CHF is a heart condition that happens when your heart can’t adequately pump blood to give your body a normal blood supply. This causes blood and fluids to collect in your lungs and legs. As this piles up, it can result in a wide-range of symptoms, including: chest pain, swelling, heart palpitations, weight gain, etc. Managing these symptoms requires long-term treatment, use of medications and ongoing care management.

  • Chronic Obstructive Pulmonary Disease (COPD):
    COPD is a chronic lung condition that includes conditions such as chronic bronchitis and emphysema. CCM can assist individuals with COPD in managing their symptoms, optimizing medication use, providing smoking cessation support, and coordinating pulmonary rehabilitation services.

  • Asthma:
    Asthma is a chronic respiratory condition that requires ongoing management and monitoring. CCM can help individuals with asthma understand their triggers, manage medications effectively, develop an asthma action plan, and improve self-care techniques.

  • Chronic Kidney Disease (CKD):
    Individuals with CKD often require ongoing monitoring of kidney function, managing associated conditions (such as hypertension and diabetes), and implementing dietary modifications. CCM can help coordinate care and educate patients on how to slow the progression of CKD.

  • Mental Health Conditions:
    Some mental health conditions, such as depression, anxiety disorders, and bipolar disorder, may qualify for CCM. Integrated care models that address both physical and mental health aspects can provide comprehensive support for individuals with these conditions.

Other conditions that qualify for CCM, include cancer, ischemic heart disease, osteoporosis, atrial fibrillation, arthritis, drug abuse, autism spectrum disorders, psychotic disorders, stroke, HIV, hepatitis, hyperlipidemia & Alzheimer’s disease.

What Reimbursements Are Available for CCM Services?

To encourage broader expansion of CCM services across healthcare providers, CMS significantly increased reimbursement rates for CCM in 2022, in some cases by more than 50%. The following is a list of the current Chronic Care Management CPT codes, as of 2023, along with the average reimbursement rates corresponding to each code.

CPT Code Description Reimbursement *
99490 Standard CCM, 20 mins Clinical Staff Time Per Calendar Month $62
99439 Standard CCM Add-On, Each Additional 20 mins Clinical Staff Time Per Calendar Month, Up to Two Times $47
99487 Complex Care CCM, 60 mins Clinical Staff Time Per Calendar Month $133
99489 Complex Care Add-On, Each Additional 30 mins Clinical Staff Time Per Calendar Month $70
99484 Behavioral Health, 20 mins Clinical Staff Time Per Calendar Month $43
*actual reimbursement varies by region.

More details on 2023 CCM reimbursements can be found here on the Signallamp website.

How to Enroll Patients in CCM?

There are two core components to consider enrolling patients in CCM:

  1. Compliance – To ensure compliance with CMS guidelines for enrolling patients in your chronic care management program, patients must first be eligible for the program. To be eligible, patients must have two or more chronic conditions and have been seen by you for an office visit in the past twelve months. You can usually run a report to filter for eligible patients using tools within your EMR.

    Once you have identified the eligible patients you begin outreach to those patients for enrollment in your CCM program, you must obtain & document consent from each patient that opts to enroll. Verbal consent is allowed, but must be documented.

    You will also want to verify insurance coverage when speaking with each patient to confirm they have active Medicare and/or Medicare Advantage insurance. While not required, it is recommended to perform an electronic insurance verification to confirm what the patient reports and what you have on file are all matching up.

  2. Patients – Now that you have confirmed patient eligibility and have a process in place to ensure compliant documentation of the patient’s consent & insurance coverage, actual enrollment success (and retention) will depend on how well you communicate the program to the patient.

    There are clear benefits to the patient, including: Access to a dedicated nurse care manager to help them better manage their chronic conditions, provide triage & early intervention when new symptoms occur, medication reconciliation & refill assistance, help scheduling visits with their PCP or specialist, assistance in accessing community based resources, etc.

    You should always administer the program as an extension of the patient’s primary care physician and clearly communicate to the patient that their dedicated nurse care manager is working together with their physician and will be documenting everything in your EMR so that their physician has access and will be collaborating directly with the nurse when interventions are required.

    It is also important to communicate to patients that CCM is considered a billable service and to clearly explain any financial impact to the patient, such as copay, coinsurance and/or impact on deductibles. In many cases, there may not be any copay or coinsurance, e.g., traditional Medicare patients that have secondary insurance as well. However, copay will vary amongst Medicare Advantage plans (assuming the plan supports CCM reimbursements), and it is important to be upfront with patients for those that will have a copay. This will result in fewer billing complaints and higher patient retention in the program long-term.

Summarizing the Guide

This ultimate guide has provided valuable insights into the key aspects of CCM.

We explored the definition of CCM and how it benefits patients, emphasizing the importance of proactive management, patient engagement, coordinated care, and the involvement of providers and practice staff. CCM empowers patients to take an active role in their healthcare, equipping them with knowledge, tools, and support to better understand and manage their conditions.

The guide highlighted the goals of CCM, including improved health outcomes, enhanced patient engagement, care coordination, preventive care, and patient satisfaction. By focusing on these objectives, healthcare providers can help patients achieve better control of their chronic conditions, prevent complications, and optimize their overall health and well-being.

We also discussed the conditions that commonly qualify for CCM, such as diabetes, hypertension, cardiovascular diseases, COPD, asthma, chronic kidney disease, and certain mental health conditions. It’s important to note that eligibility may vary based on specific program criteria and provider policies.

We closed it out by talking about the reimbursements available for CCM services and ultimately how to enroll patients in CCM.

Overall, chronic care management offers a holistic and personalized approach to healthcare for individuals with chronic conditions. By implementing CCM strategies, healthcare providers can deliver coordinated, comprehensive, and patient-centered care that empowers patients to actively manage their health, resulting in improved outcomes and a better quality of life.

Patients: As you embark on your chronic care management journey, it’s crucial to work closely with your healthcare team, follow your personalized care plan, stay engaged in your own care, and seek support when needed. That’s exactly what we at Signallamp promote. For Health Systems and Physician Groups who are interested in learning more about Signallamp’s Chronic Care Management Platform, schedule some time to talk with us today!