What Are the Key Goals of Chronic Care Management?

Chronic Care Management (CCM) can help patients achieve improved health outcomes. The Centers for Medicare and Medicaid Services (CMS) estimated that 68% of patients with Medicare fee-for-service benefits qualify for CCM services. Since 2015, quality Chronic Care Management programs have saved and improved the lives of chronically ill patients across the country. This service has connected patients to essential care tools that have changed their lives forever. Through services like care coordination, patients can stay on top of their care plan, access the resources they need, and achieve improved health outcomes. Below are four ways your practice and patients can benefit from Chronic Care Management.

4 Benefits of Chronic Care Management:

Enhance Quality of Care

Patients who have been diagnosed with multiple chronic conditions often have a complicated care landscape. They may be seeing multiple providers and specialists across numerous health networks. This can be difficult to manage. With Chronic Care Management, patients can keep track of the many moving parts of their care. Rather than having different providers, not on the same page, their care team can work together. A coordinated care team works collaboratively to make sure every area of the patient’s care is orchestrated as one moving piece. Care coordination ensures that patients have the extra help they need.

Prevent Gaps in Treatment

Sometimes patients with multiple chronic conditions have gaps in their care. This could be due to many reasons, such as poor communication, disorganization, or a failure on the provider’s end. Regardless, Chronic Care Management helps to prevent gaps in care. This program ensures someone is touching base with the patient at least once a month to ensure they are on track to achieve the best health outcomes possible.

Improve Health Outcomes

By having someone hold patients accountable for their care plan, patients are more likely to achieve improved health outcomes. These care coordination specialists are always available to answer patient questions. Care coordination is also helping patients keep track of their medications and alert providers of any new developments or red flags in their care. With all of these moving parts working together, patients who utilize Chronic Care Management achieve better results and outcomes.

Generate Additional Revenue

For providers, Chronic Care Management could mean a significant boost in revenue. Practices can earn up to an additional 85k in revenue each year per billing provider within their organization. Working with a quality partner in CCM services can help you optimize your Chronic Care Management program so that you may achieve optimal revenue. They will work as an extension of your practice to ensure your patients are getting the best help possible.

To learn more about a quality vendor of Chronic Care Management services, click here.

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The Keys to an Effective Chronic Care Management Program


Communication is one of the most critical components of a Chronic Care Management program. This includes communication with current program participants and communication with potential eligible patients. You need to make sure you have a quality team ready to jump in and help patients at a moment’s notice. Whether it’s a patient’s monthly phone call, or a patient reaching out for medical assistance, communication is key to success.

Educate Your Staff

Every member of your practice team from the front office to the back-of-house billing needs to be educated on the program’s inner workings. Education across the entire team is vital for a successful Chronic Care Management program. Educating front office staff will help bring the program to the attention of potential participants. Educating the back-of-house billing department will help optimize reimbursements. Educating and training everyone in-between will streamline the program to ensure patients receive the best care.

Right Frame of Mind

Implementing a new program can be intimidating and frustrating. For this reason, you need to make sure your team is prepared and on board with the Chronic Care Management implementation process. The more staff ready to learn and apply, the easier the program will be established. The smoother the transition process goes, the faster the practice can begin offering patients their best chance at a quality outcome and start bringing in an additional revenue stream.

Utilize a Quality Vendor

A quality Chronic Care Management partner is the key to this entire equation. An experienced and established vendor can smooth every single part of the process. They can help prepare, inform, and train the whole team on the inner workings of care coordination services. They can connect the practice to tools and resources that will help optimize the program. In addition, they can also manage the program for the practice rather than host an in-house team. A quality vendor will work as an extension of the practice to optimize the Chronic Care Management program.

To learn more about iSalus, click here.

Chronic Care Management (CCM) has been a wildly successful venture for many healthcare providers. It is helping patients achieve incredible outcomes through the alignment of their providers, care coordination, and complex and comprehensive health plans they can keep track of. Patients who were likely to have a poor quality of life due to their chronic conditions now see remarkable results.

Providers are also reaping significant benefits from the implementation of CCM programs. Chronic Care Management has the potential to help providers boost their bottom line and improve the quality of care they can provide to patients. The key to a successful Chronic Care Management program is to get off on the right foot.

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Best Chronic Care Management Practices

Understand the Policy

Too many providers have jumped headfirst into implementing a CCM program they do not fully understand, leading to failure. Understanding aspects of CCM like which patients qualify, visit requirements, and your team’s role is crucial to success in rolling out this program in your practice. Understanding the policy behind Chronic Care Management creates the foundation for success.

Understand Who Can Bill

The billing component of Chronic Care Management can seem quite overwhelming. It is essential to understand exactly who is eligible to bill for CCM visits in your practice. Qualified professionals that can bill for CCM include physician assistants, clinical nurse specialists, nurse practitioners, certified nurse midwives, and eligible physicians.

Educate Your Patients

For patients to reap the benefits of a quality Chronic Care Management program, they need to understand how it can help them. Invest time and resources into educating your eligible patients about what CCM can offer them. Share educational materials with them during visits, over the phone, and around your building. The more they know about this care option, the more likely they are to sign up.

Get Patient Consent

Once a patient understands how Chronic Care Management can benefit them, your practice needs to get their consent. Written consent from a patient will allow you to enroll them in your practice’s CCM program and start caring for them in this way.

Establish Comprehensive Care Plans

To adhere to CMS CCM requirements, providers need to have a comprehensive digital care plan for every patient enrolled in the program. A care plan should include a thorough assessment, a list of their current problems/conditions, a treatment plan and goals, resources associated with their care, and medication management.

Track Everything

Your practice must track everything that relates to a CCM patient’s care. This should include the time you spend with them in the office, over the phone, and any other time dedicated to their care. Your documentation should detail the time you spent on them and what was included in the interaction.

Outsource CCM Services

The most important thing your practice can do to optimize your chronic care management program is to outsource these services to a highly qualified vendor who can help your team maximize return, improve patient care, and adhere to all CCM compliance. To learn more about a qualified CCM vendor, click here.

iSalus | Chronic Care Management

How do Chronic Care Management Programs Improve Revenue?

Get Paid for Services You Already Provide

Many providers are already caring for many CCM-eligible patients. Implementing a quality chronic care management program can reinforce revenue for the services you are providing to your patients while ensuring they are getting the highest quality of care.

Recurring Revenue

A quality CCM program introduces an entirely new revenue stream to your practice. By outsourcing your CCM program to a qualified vendor, your practice can earn up to 85k a year per billing provider within your organization. This recurring revenue improves the health of your bottom line without straining your team.

Optimize Staff Time

Chronic care management programs were established in 2015, and since then, qualified vendors have had time to perfect the process to help your practice. The vendor works as an extension of your practice to ensure your patients get everything they need including care coordination and prescription assistance. Partnering with a vendor removes much of the burden of a CCM program from your staff while allowing you recognize the financial benefits.

Improve Quality of Care

Without a quality chronic care management program, it is difficult for you to optimize the care of your patients with a chronic illness. With the right program in place and the right partner by your side, providers can change the lives of their patients. Care coordination, monthly check-ins, prescription assistance, community engagement, and more help your patients achieve better outcomes throughout their illness.

To learn more about a quality CCM partner, click here.

Benefits of Outsourcing Chronic Care Management

Scheduling Assistance

Providers that outsource CCM services gain access to high-functioning scheduling assistance. Managing all the components of a patient’s chronic illness can be time-consuming and frustrating for your patients. If your patient needs to consult with multiple providers and specialists they can easily become overwhelmed, miss a visit, or fall behind. By outsourcing chronic care management, your practice will gain access to scheduling assistance that helps everyone. A CCM expert works with patients directly to schedule their appointments and remind them of upcoming visits. With the help of a qualified vendor, practices can decrease no-show visits and increase patient engagement, improving results.

Prescription Assistance

For your patients who are battling with chronic illness, they are often trying to keep track of many different medications. When your patient is seeing multiple providers, they may lose track of the details. This can yield dangerous consequences, like taking conflicting medications or too much of a single medication. With the help of a CCM vendor, your patients can stay on track. A vendor should offer medication reconciliation services to ensure that there are no conflicts within a patient’s prescriptions. They will help you make sure your patient is taking their medication as directed, improving their results.

Community Assistance

Outsourcing CCM services can help your patients in a wealth of other ways outside of your practice. A qualified CCM vendor will work directly with patients to connect them to other resources in their community, such as discounted prescriptions, community resources, and more. Your patient’s increased connection and engagement with both their provider and their community can lead to better outcomes.

Implementing a high-functioning chronic care management program does not have to be a strain on your organization. By outsourcing CCM services to a qualified vendor, your practice can optimize patient care, introduce a new line of revenue, and improve the lives of patients battling tough chronic illness. To learn more about a vendor of services that can help you, click here.