Chronic Care Management: The Ultimate Guide [2022] - H3C

You’ve heard about chronic care management programs. But you’re uncertain what using one would mean for your clinic. Undoubtedly implementing a chronic care management (CCM) program will take time, staff, and money to name a few things—but what are the hidden challenges?

And what are the benefits of using an outsourced chronic care management program versus simply doing it all yourself?

Below we will delve into all aspects of CCM programs including what they are, their benefits and challenges, and a whole lot more.

Yes, it’s the industry’s most up-to-date guide—start finding all the answers to your questions, now!

What is Chronic Care Management (CCM)?

Chronic care management (CCM) focuses on serving individuals on Medicare with two or more chronic conditions. CCM is a preventative service, helping your eligible Medicare patients take a proactive approach to their health and wellness, while keeping them connected to their provider.

According to recent statistics, 80% of chronic diseases could be eliminated by preventative measures. Also, two-thirds of all deaths in America are attributable to one of five chronic disorders: cancer, chronic obstructive pulmonary disease, diabetes, heart disease, and stroke.

A good CCM program can aid your clinic in facilitating earlier interventions among patients, encouraging compliance with medication regimens, supporting lifestyle improvements, and even reducing the number of hospitalizations, complications, and unnecessary ER visits that your patients may face.

What conditions qualify for chronic care management?

A CCM program can provide help for patients who face at least two chronic conditions which are expected to last at least 12 months. Patients must consent to being in the program and each patient will require a care plan. Encounters must last at least 20 minutes each month and can go up to 60 minutes.

Should a patient’s conditions meet the proper criteria set forth by Medicare, they are eligible for a chronic care management program.

The population faces a slew of chronic conditions. Your clinic is likely familiar with many of them, but here is a list of some of the more common ones. Here are some of the conditions that qualify for chronic care management:

• Alzheimer’s disease
• Arthritis
• Asthma
• Autism
• Blindness
• Cancer
• Cardiovascular disease
• Deafness or hearing impairment
• Diabetes
• Endometriosis
• Epilepsy
• Fibromyalgia
• Heart disease
• High blood pressure
• HIV / AIDS
• Hypertension
• Migraines
• Obesity
• Psoriasis
• Sickle Cell Anemia
• Sleep apnea
• Thyroid disease
• Tuberculosis

How does chronic care management work?

A CCM program helps to improve patient experiences and outcomes while boosting both your clinical value and its revenue. Whether in-house or outsourced, a CCM program should be staffed by qualified, licensed clinicians who conduct the monthly patient encounters. While the path to success varies by clinic, here are four common steps to take toward establishing a CCM program:

1. Identify patients who qualify and make the connection.
2. Enroll interested patients.
3. Provide monthly phone calls for each enrollee from a dedicated representative who understands their current medical challenges.
4. Integrate patient assessments from each call directly into your EMR system offering providers a more constructive conversation with their patients during office visits.