How Practices Can Implement Chronic Care Management (CCM)

Practicing Chronic Care Management

If you have patients that deal with chronic conditions, you know that you have to address their concerns differently than other conditions.

The Center for Disease Control (CDC) and the Centre for Medicare & Medicaid Services (CMS) both recognize the importance of approach when dealing with patients that have chronic conditions. 21% of Americans between the ages of 45 and 64, according to the CDC, deal with two or more chronic conditions, with the percentage increasing to 45% for those 65 and older.

Because these conditions cannot be cured with medical interventions, managing these patients’ care is key to maintaining positive health outcomes and high quality of life.

Chronic care management (CCM) consists of all the strategies used to educate, oversee, and manage care for chronic conditions. It entails communication between patient and healthcare workers, managing their medications, and creating and revising care plans. Nowadays, most  CCM practices are provided remotely via telephone or online.

So how can a practice implement a CCM program?


Steps To Implementing Chronic Care Management

Identify Who You Will Serve

Use your EHR to identify patients who may be a good fit for your CCM program. Check their eligibility with the CMS if they have Medicaid or Medicare.

Focus on specific diagnoses, such as diabetes, Alzheimer’s, or COPD.

Educate Patients on Services

In order for your CCM program to have success, your patients need to know about its benefits. Let your patients know at every opportunity that you provide CCM and that they may be eligible for reimbursement by Medicaid or Medicare.

Begin Enrolling Patients

To start enrolling patients, you’ll need to verify that they’re eligible, have a face-to-face visit to discuss the program, and get their consent.

However, it’s not enough for patients to be on board: your staff needs to know the details of the program and what it entails. Training your staff on CCM will help make implementation much easier.


Bill for Reimbursement

Reimbursement requires that the practice keep a clear audit trail.

As well, only one clinician can bill for CCM services for a particular patient. Since many people with chronic conditions have multiple care providers, they’ll need to understand that they can only have one clinician billing for CCM.


Work with a Trusted CCM Partner

This is an important consideration, as a trusted CCM partner will help ease the strain on resources that providing CCM services can cause. A good partner will take care of most of the troublesome parts.

Outsourcing CCM is one of the best ways that practices can provide quality CCM without causing too much of a burden on the practice.