Value-based care is increasingly becoming the standard in healthcare, pushing providers to adopt proactive strategies that genuinely improve patient outcomes. Chronic Care Management (CCM) has emerged as a pivotal program in this shift. In fact, by early 2025, a significant 53.4% of traditional Medicare beneficiaries were already engaged in accountable care relationships with their healthcare providers, and the goal is to reach universal participation by 2030. As the population of individuals managing multiple chronic conditions expands, transitioning to value-based care models can present complexities for healthcare practices. Determining which programs warrant investment to yield tangible patient benefits can be a daunting task. Chronic Care Management rises to this challenge, offering substantial advantages for patients while simultaneously enabling practices to effectively embrace value-based care principles.
Exploring the Core Benefits of Chronic Care Management
The Chronic Care Management program is designed to provide consistent support to Medicare patients dealing with multiple chronic conditions. This support includes regular proactive check-ins, facilitated access to necessary resources, medication management assistance, appointment scheduling support, and crucially, 24/7 access to a dedicated care line. CCM is instrumental in helping patients navigate their health more effectively, reducing avoidable emergency department visits, ensuring timely access to care when needed, and ultimately achieving their personal health objectives. Let’s delve into the key advantages this program offers.
1. Enhanced Access to Comprehensive Healthcare Services
Traditionally, healthcare interactions often occur when patients are already experiencing illness or injury. Chronic Care Management fundamentally shifts this paradigm towards preventative care. A dedicated CCM care team proactively engages with enrolled Medicare patients monthly through both telephone and electronic communications.
Care coordinators commit a minimum of 20 minutes each month to each participating patient’s care. This dedicated time is meticulously documented and is billable under CPT code 99490. This proactive outreach allows healthcare providers to deliver preventative services specifically tailored to the patient’s chronic conditions, intervening before their health status potentially deteriorates. These interactions can involve assisting patients in setting achievable health goals, enhancing their understanding of their conditions, and connecting them with vital resources such as transportation services and meal delivery programs.
Beyond preventative measures, a critical component of Medicare’s CCM requirements is the provision of 24/7 access to a phone-based care line. This dual approach – proactive preventative outreach coupled with round-the-clock availability – is what makes Chronic Care Management such a robust and impactful program. This improved access to care inherent in CCM is specifically designed to mitigate or slow down functional decline in patients and has been clinically proven to decrease both hospitalizations and emergency room visits.1
2. Significant Healthcare Cost Savings for Patients and the System
Despite a modest monthly co-insurance requirement, enrollment in a CCM program has demonstrably led to reduced annual healthcare expenses for eligible patients. Chronic Care Management services contribute to these savings in several key ways:
- Preventative Care Reduces Acute Episodes: By focusing on prevention, CCM helps patients maintain better health and avoid costly hospital admissions.
- 24/7 Care Line Diverts Non-Emergencies: The availability of a 24/7/365 care line, staffed by nurses trained in Schmitt-Thompson triage protocols, effectively reduces the likelihood of patients seeking emergency room care for issues that are not actually urgent.
- Direct Access to Healthcare Professionals: The continuous care management access enables patients to directly address their health-related questions to qualified healthcare professionals promptly, preventing minor concerns from escalating into major, costly problems.
Medicare claims data provides compelling evidence of the cost-effectiveness of CCM, revealing that participation in CCM can decrease unnecessary hospital visits by at least 4.7% and emergency department visits by 2.3%.1 Furthermore, Chronic Care Management generates estimated savings for Medicare of approximately $74 per patient each month.2 These financial benefits represent a significant advantage of Chronic Care Management for both patients and the broader healthcare system.
3. Empowerment to Achieve Personal Healthcare Objectives
Care management clinicians play a crucial role in equipping patients with the necessary tools and knowledge for effective self-management of their chronic conditions. Clinicians address each patient’s specific chronic conditions on an individual basis, collaborating with their primary care physician or specialist to establish personalized goals aimed at improving their overall health outcomes. These collaboratively defined goals are meticulously documented within a comprehensive care plan and are consistently referenced during every interaction with the patient.
An effective Chronic Care Management program hinges on the creation and maintenance of a comprehensive care plan that is readily accessible at any time. This plan serves as an all-encompassing repository where the care coordination team meticulously records every patient interaction. It also includes the patient’s detailed medical history, a complete list of their healthcare providers, a thorough record of their health conditions, and a current medication list. This comprehensive care plan is securely stored within the provider’s electronic health record (EHR) system, ensuring accessibility for the patient, their providers, and any authorized caregivers.
Addressing Potential Challenges in CCM for Patients
While the benefits of CCM are substantial, it’s important to acknowledge that the program is not without potential challenges. Some common hurdles that patients might encounter within a CCM program include:
- Healthcare System Strain: The healthcare sector often operates under significant strain. Providers and in-office staff may find it challenging to consistently deliver remote, preventative care to CCM patients while simultaneously maintaining high-quality care for patients seen in person.
- Patient Education Gaps: Many patients lack a complete understanding of their chronic conditions and are unsure about the necessary steps for improvement. For instance, a patient who doesn’t fully grasp the function of their medication might inadvertently skip doses or take it incorrectly, affecting its efficacy. CCM can help bridge these gaps, but this requires consistent access to evidence-based patient education materials. Insufficient patient education can lead to non-adherence to medication or care plans, potentially worsening health outcomes.
- Care Coordination Complexities: CCM patients often receive care from multiple specialists and providers, making care coordination and seamless information sharing a complex undertaking. One provider may not be fully informed about a new diagnosis or medication prescribed by another, leading to an incomplete clinical picture and potentially impacting the quality of care.
- Monitoring and Follow-Up Inconsistencies: Regular follow-up appointments are essential to ensure that providers remain updated on patient progress and address any emerging concerns. Inconsistent or absent follow-up can diminish patient accountability and negatively impact health outcomes. Lack of effective coordination among providers frequently contributes to this issue.
Overcoming these challenges necessitates a well-structured and organized approach to preventative care, including a dedicated, adequately staffed, and knowledgeable CCM team. Some practices find it difficult to establish this level of in-house support due to the investments required in training, technology, and staffing. While a fully-managed CCM program cannot eliminate all inherent challenges, partnering with a specialized provider can empower practices to access highly trained personnel capable of delivering effective patient education, coordination, and comprehensive support to their Medicare patients.
How a Fully-Managed CCM Program Maximizes Patient Benefits
Opting for a fully-managed CCM program allows healthcare practices to leverage a dedicated team focused solely on delivering preventative care between scheduled appointments. This team assumes responsibility for the routine tasks of CCM, such as proactively reaching out to patients, updating care plans, and ensuring seamless care coordination with all providers involved. Managed CCM solutions can significantly enhance and expand the reach of your Chronic Care Management program without placing additional burdens on your practice staff, allowing your in-office team to concentrate on delivering in-person care.
A high-quality CCM program should operate as a seamless extension of your existing team, collaborating closely with your practice to provide care that is fully aligned with your practice goals. You will receive regular updates and can effortlessly integrate CCM data into your established clinical and administrative workflows.
A fully-managed CCM partner contributes to improved patient care through several key services:
- 24/7 Clinician Communication: Patients have round-the-clock access to clinical support. Should questions or concerns arise, they can readily connect with a clinician for prompt, informed guidance.
- Comprehensive Enrollment Services: Identifying and enrolling eligible patients is an ongoing process often overlooked. A managed program takes ownership of this critical step, handling patient outreach and enrollment processes.
- Regular Performance Reporting: You receive consistent, detailed reports and documentation, keeping you informed about patient interactions, time allocated to care delivery, and patient status updates.
- Logistical Support for Patients: The CCM team assists patients with essential logistical tasks, including scheduling appointments, managing medication refills, and accessing test results. They can also provide support in finding transportation, meal assistance, housing resources, mobility solutions, and home healthcare services.
- Medicare Compliance Assurance: Medicare has specific requirements for CCM programs. A managed service provider diligently monitors all aspects of the program to ensure ongoing compliance.
By partnering with a managed service provider, healthcare practices can fully leverage the potential of their CCM program. This enables them to enhance patient care quality, optimize revenue streams, and maintain their focus on delivering excellent in-person care.
Alt text: Contact ChartSpan to discover how a managed Chronic Care Management program can benefit your patients and practice.
ChartSpan: Empowering Your Team for CCM Success
The advantages of CCM are undeniable, particularly for patients. Preventative care, coupled with expanded access to resources and continuous support, leads to improved overall health and more effective healthcare access. This enhanced access directly translates to fewer hospitalizations and emergency room visits, ultimately driving down overall healthcare expenditures. Furthermore, better managed care significantly improves patient outcomes and empowers individuals to achieve their personalized healthcare goals. For healthcare providers committed to transitioning towards effective, evidence-based value-based care models, a program like Chronic Care Management is not just beneficial for patients with chronic conditions—it is fundamentally vital for the future of our entire healthcare system.
The ChartSpan team is dedicated to simplifying and optimizing CCM for both healthcare providers and their patients. As a seamless extension of your practice, ChartSpan collaborates with you to effectively serve your patient population without overburdening your existing staff. ChartSpan’s robust program is designed to support a diverse range of practice settings, including primary care, specialist practices, Federally Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs). ChartSpan provides comprehensive support at every stage, from patient enrollment to billing processes, and seamlessly integrates with virtually any EMR/EHR system. To explore the full spectrum of benefits that preventative care and a managed CCM program can offer your practice, we invite you to review our concise guide to value-based care.
1 https://innovation.cms.gov/files/reports/chronic-care-mngmt-finalevalrpt.pdf
2 https://acl.gov/sites/default/files/programs/2017-12/TIM%20TALKS_Business%20Planning_Care%20Management_May%2031_2017.pdf
