Chronic Care Management (CCM)

Chronic Care Management (CCM) is a Medicare program designed to help patients maintain their chronic health conditions. It aims to offer patients continuous support and access to healthcare between appointments, even when they are at home. To qualify for CCM, a patient must be a Medicare beneficiary and have at least two chronic health issues expected to last a minimum of one year or for the rest of the patient's life.

What does CCM include?

CCM services involve organized documentation of patient health details and the development of thorough electronic care plans. It also includes overseeing transitions in care and other aspects of managing care. In addition, CCM encompasses managing medications, coordinating patient care, and promptly sharing health information both within and outside the practice.

How does CCM benefit healthcare providers?

Patients with multiple chronic conditions can present complex challenges in terms of management and coordination of care. They may consult with various specialists or be on several medications, necessitating collaboration among healthcare professionals. Ensuring proper coordination means that providers can access critical health information and test results promptly when needed. Integrating CCM into patient care allows providers to maintain consistency and offer the best comprehensive care. Additionally, CCM can reduce staff workload and minimize non-billable time. By encouraging patients to take an active role in their healthcare, providers can streamline processes and make patient management more efficient.

How does CCM benefit patients?

CCM prioritizes a continuous and personalized relationship between patients and their chosen care team members. This helps patients with chronic illnesses work toward their health goals while benefiting from 24/7 access to care and health information. Patients receive preventive care and are more engaged in their health journey, as are their caregivers. CCM also facilitates the prompt sharing and utilization of patient health information. Patients with multiple chronic conditions often face complex care needs that can be difficult to manage independently. Working with a care manager can provide crucial support in addressing their individual medical requirements. CCM enhances care coordination, offering services outside of typical clinic visits and enabling patients to navigate their care more effectively.