Deliver Best Practices For Chronic Care Management

Chronic Care Management

June 24th, 2022   |   Updated on June 27th, 2022

Chronic care management is a telehealth subset similar to remote patient monitoring and entails continuous, coordinated monitoring and treatment of chronically ill patients in a virtual manner.

CCM programs enable physicians and care providers to keep constant tabs on chronic disease sufferers and provide treatment recommendations electronically from their place of choice.

Patients can stay in the comforts of their homes and don’t have to take the hassle of regularly traveling to their doctor’s clinic for accessing medical care when enrolled in a CCM program.

The Centers for Medicare and Medicaid Services (CMS) offers reimbursements to healthcare practices against CCM services. If you are a healthcare practice looking to tap into an extra stream of revenue while also improving patient outcomes, you should implement a CCM program.

Before you jump on the CCM bandwagon, it’s important to know certain best practices that can help you succeed in the implementation as well as operation of your CCM program. Read along as in this article, we will discuss in detail about chronic care management best practices.

Checking Patient Eligibility

Before you start an outreach campaign to attract patients to your CCM program, you should know the eligibility criteria for CCM patients. A patient is eligible to receive care under CCM if-

-He/she has two or more chronic illnesses

-The chronic illnesses are expected to last at least 12 months or till their death.

-The chronic illnesses must put the patient at high risk of death, severe aggravations and functional decline.

Some examples of chronic conditions that make a patient eligible for CCM are:

-Cardiovascular disease




-Chronic obstructive pulmonary disease

Knowing Who Can Bill For CCM Services

Only one practitioner, federally qualified health center (FQHC), rural health clinic (RHC) and hospital can receive CCM reimbursement for a patient each month. Along with physicians, the following non-physician individuals can bill the CMS for CCM services –

-Clinical nurse specialists

-Nurse practitioners

-Certified nurse midwives

-Physician assistants

To successfully bill the CMS and receive reimbursements on time, it’s important to know who is the right practitioner to file the bills.

Obtaining Patient Consent

Before recruiting patients to your CCM program, you need to obtain and document their written or verbal consent. You can attract multiple enrollees by conducting outreach campaigns but only patients who provide you with their consent will be considered as the authentic enrollees of your CCM program and you will be able to bill CMS for care delivered to these patients.

You should create consent forms and documents that painstakingly highlight the services you will deliver under your CCM program. These forms can then be distributed to patients showing interest in your program to be filled by them and documented for presenting to the CMS when billing.

You should explain to potential enrollees in detail that they can opt out of the program anytime they want and only a single practitioner will deliver CCM services to them each month.

Furthermore, you should discuss what results patients can expect from your CCM program and what costs must be borne by them and which expenses will be incurred by Medicare.

Creating A Comprehensive Care Plan

Care plan creation is an essential practice in any CCM program and is what serves as a guideline for care providers to engage patients regularly.

Physicians and practitioners handling a patient under CCM must create their dedicated, personalised electronic care plan that can be accessed anytime. A care plan must consist of-

-A detailed assessment of the patient’s physical, mental and psychological condition as well as other details relevant to their illnesses.

-A comprehensive list of the ailments the patient suffers from with focus on chronic diseases.

-Details about the recommended treatment, its objectives and long-term impacts.

-A record of all individuals and organisations involved in a patient’s treatment including their various doctors and care providers.

-Details about their ongoing medication regimes

These care plans must be created with utmost accuracy and preciseness to ensure zero discrepancies in treatment and care coordination.

Tracking Time Spent On Care

Tracking and documenting the time spent delivering care services under your CCM program to each patient is important for successfully receiving reimbursements from the CMS.

You should precisely track the time for which you engage each patient in non-face-to-face CCM services. These services can include, calls and online consultations with patients, prescription management, medication reconciliation, and care coordination efforts among others.

Partner With A Care Coordination Service

If you are a healthcare practice and all or most of the aforementioned CCM best practices seem daunting for you to implement and manage, you should look to partner with a professional care coordination service. It’s a possibility that you don’t have the necessary workforce or resources to aptly manage the various complex CCM operations.

Instead of investing heavily in hiring staff and procuring high-end technological resources to build CCM capabilities from scratch, you can partner with a care coordination service that already has all the required solutions and expertise to help you excel in your CCM efforts.

Even if you do have all the resources, it can be challenging to initiate a profitable CCM program without prior expertise in the telehealth and CCM domain.

Furthermore, it can be generally hassling to ensure everything is working seamlessly in your CCM program day in and day out and can make you lose focus on other essential operations of your healthcare practice.

Instead, you should entrust all your CCM requirements to a reputable care coordination service and see your CCM program generate profits from the get-go.

Health Disclaimer :

Information provided by does in no way substitute for qualified medical opinion. Any text, videos or any other material provided by us should be considered as generic information only. Any health related information may vary from person to person, hence we advice you to consult specialists for more information.