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.
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.
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:
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.
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:
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.
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:
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.
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 |
More details on 2023 CCM reimbursements can be found here on the Signallamp website.
There are two core components to consider enrolling patients in CCM:
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.
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.
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!