Chronic Care Management

What is Chronic Care Management?

If you are a Medicare beneficiary, you may qualify for chronic care management (CCM). CCM is one of multiple covered Medicare programs that allow a healthcare provider to manage and coordinate patient care between traditional office visits. CCM is beneficial for patients in terms of ongoing health and wellness support, increased access to appropriate medical resources, enhanced communication with members of their care team, reduction in emergency room visits and hospitalization or readmissions, and increased engagement in their own healthcare.

Goals of Chronic Care Management

People with multiple chronic conditions are at an increased risk for poor quality of life. The goal of CCM is to help patients achieve a better quality of life through continuous care and management of their conditions. In a CCM program, a patient might have reduced pain and stress, increased mobility and physical fitness, and better sleep and relaxation. Ideally, a patient would be able, to some extent, to return to the activities, like work or hobbies, that their chronic conditions have prevented them from.

Understanding Chronic Care Management

A disease or condition is chronic when it lasts a year or more, requires ongoing medical attention, limits the activities of daily life, or puts them at significant risk of acute exacerbation or functional decline.

Under CCM, the patient’s care team can create more continuity in managing a patient’s conditions. CCM provides services that are outside of face-to-face patient visits. This includes formulating a comprehensive care plan, communication and management (usually over the phone), medication management, and coordination of care between providers.

CCM involves a comprehensive care plan that helps in the coordination of a patient's care. It includes:

a record of the patient’s chronic conditions
goals
health care providers
medications
any other services needed to manage their condition

Our partners at Medsien

To help provide CCM services, we have partnered with a group called Medsien. If you are a Medicare beneficiary and qualify for CCM, a certified medical assistant may contact you to see if you are interested in enrolling in the program. Alternatively, you may enroll in the program by contacting our office. You can terminate the program at any time. Please click here for more information from Medsien.