7 Tips to implement Chronic Care Management Program

Chronic Care Management

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CCM, also known as chronic health management (CCM), is a highly effective method to help those suffering from chronic illnesses even after they have left the physician’s office. It lets them easily connect with the care team and receive personalized, ongoing health plans that are accessible via the convenience of a remote service. The practice also gains from this approach to aid patients with managing their illnesses and cutting expenses through reimbursement from the Centers for Medicare & Medicaid Services (CMS).

Making the most of these programs requires some planning. Many firms attempt to offer the CCM service without knowing the CCM requirements. They could have to deal with various issues, such as staffing, training, or even documentation. Although CCM programs provide substantial benefits, bad implementation practices could cause them to fail.

What Is The Reason Why Some CCM Implementations Fail?

CCM programs might seem straightforward at first glance. However, you must manage various aspects to ensure that your program is viable and effective within your practice. In everything from the number of staff to documentation processes, be sure you’ve taken care of the following aspects before beginning your program for chronic care management:

Adequate Staff Size

A common error that people make is not having adequate staff size for running CCM program. CCM can quickly overburden your experienced experts if there aren’t enough people. CMS requires that care managers be at least one among the following:

  • Practitioner
  • Registered nurse (RN)
  • Practical nurse with a license (LPN)
  • Medical assistant certified (CMA)
  • In certain areas where health coaches are not available, they can help.

The professionals will spend an average of 20 minutes each month with every patient. Based on the scale of your clinic, the practice will probably require a full-time job or even more. Inflicting this burden on staff members with other responsibilities could cause them to be more frustrated and result in lower treatment quality.

Quantity of Qualified Patients 

According to CMS, the qualifying patients include those suffering from multiple chronic illnesses, which are anticipated to last at least 12 months or until the passing away of the patient. These conditions must also place the patient at significant risk of acute exacerbation/decompensating, death, or functional decline.

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The Chronic Conditions Data Warehouse (CCW) collaborated with CMS to develop an inventory of diseases. They include cancer, diabetes, hypertension, and chronic kidney diseases. Other categories cover mental health issues such as anxiety and depression and other conditions that could be disabling, such as brain trauma or cerebral palsy, as well as mobility impairments.

Many patients meet the requirements for CCM. A little over 30 percent of American adults suffer from multiple chronic illnesses. However, that percentage increases substantially for those over the age of 65. It is estimated that 76.9 percent of Medicare or Medicaid recipients aged 65 and over suffer from multiple chronic illnesses. Based on the demographics of your clinic, it could be that you have significant numbers of patients who qualify to be eligible for this program.

Requirements for Programs

Being aware of how to adhere to CMS guidelines is crucial to ensuring that your program is funded in the way it requires. Alongside fulfilling the multiple-conditions requirement mentioned previously, the guidelines for CCMs that are not complex under code 99490 comprise the following:

  • A personalized plan of care in an EHR certified by the FDA, along with an electronic copy, is given to the patient.
  • Consent of the patient in writing or by signing
  • Access to 24/7 patients to a member of the team
  • Management of care transitions
  • Communication between the healthcare team and patient
  • Minimum (20 minutes) (complex procedures require 60 mins) from clinical personnel per month non-face-to-face service directed by a doctor or other competent professional.

Understanding these rules can aid you in taking the necessary steps to simplify the billing process, enhance documentation, minimize audit concerns, and improve the overall effectiveness of the application. 

Insufficient Leadership and Intervention Champions

Researchers have discovered that an absence of accountability and support from the top management creates a greater challenge to implementing intervention strategies. Suppose the leaders of practice are dedicated to the intervention. In that case, buy-in can be a factor at all levels of the company, which will result in more resources for efficient implementation. Intervention “champions” could also be essential in helping healthcare providers support CCM initiatives.

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The Lack of Staff Buy-In

The practices may not be in the interests of their suppliers. The study above found that buy-in by providers was heavily influenced by the provider’s views and knowledge about the intervention. It includes:

  • Falsehoods
  • There’s a lot of doubt about the program’s effectiveness.
  • Information is not available.

A proper training program and plenty of information on the advantages of CCM can resolve some frequent issues that practices have to confront about purchasing providers. The software itself has to be compatible with the workflow of a physician. If it substantially adds to their workload, forces them to learn a new piece of software, or negatively impacts their work, it’s likely that they’ll be less engaged. Make sure that providers remain invested in CCM by providing a user-friendly system that provides useful tools.

Lack of Resources

Practices require the right resources to meet the demands of patients and keep staff commitment. This includes funding, staffing, and a robust software solution. Without the proper equipment, employees could struggle to meet the demands of their clients or cause more mistakes in the process.

The lack of resources typically results from poor leadership support that can impact the allocation of funds and staff. Before launching the CCM program, you’ll need to ensure access to the right resources. It is another instance where outsourcing can be useful, providing all the necessary resources in one convenient location.


Many practices do not consider how their CCM program affects how they document their procedures or in reverse. Solid documentation will reduce the chances of making mistakes and increase efficiency, freeing personnel to focus on activities in the clinical area. Documentation should be precise to guarantee proper payment and accuracy audits.

There are various ways to increase efficiency and accuracy through automation, for example, automating certain aspects of your documentation strategy and ensuring you have comprehensive safe, and secure record-keeping using the cloud. Automate manual tasks such as filing reimbursements or documenting the care of your employees.

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Tips to Create Effective CCM Plans

When the time comes to plan for and start implementing the CCM program, these strategies can make the process easier and make sure that the program is successful:

  1. Outsourcing CCM: Outsourcing your CCM program can provide access to a dedicated team of care managers and technical resources, such as 24/7 support for patients and help with enrollment, which can be difficult to manage in-house. It can also reduce the burden on your employees by introducing intuitive solutions that work seamlessly with your EHR, allowing you to save time documenting and spending more time on the things that matter.
  2. Choose a CCM Platform that Complements Your EHR: When choosing a CCM platform, it is crucial to find one compatible with your existing EHR system. However, not all EHRs are designed to meet the requirements of value-based care models like CCM, so finding a platform that can complement your EHR system and fill the gaps in functionality can be helpful. This can help you avoid documentation mistakes and streamline the workflow for providers.
  3. Identify Eligible Patients: To get the most value from your CCM program, it is important to identify eligible patients and market the program effectively to them. Using software tools or enlisting the help of a CCM service provider can help you assess your patient population, identify potential enrollment opportunities, and implement turnkey marketing and enrollment services that can make the enrollment process easier for patients and providers alike.
  4. Continuously Review and Refine Your CCM Program: CCM is not a one-time task but an ongoing process that requires continuous evaluation and refinement to achieve optimal results. Using reports provided by your CCM program can help you identify opportunities for improvement and refine your approach over time, ultimately leading to a more effective program with a higher return on investment.

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