What is Chronic Care Management?

Chronic care management includes any care provided by medical professionals to patients who have chronic diseases and conditions. A disease or condition is chronic when it lasts a year or more, requires ongoing medical attention or limits the activities of daily life. It includes physical conditions like diabetes or mental conditions, like depression. 

In the United States, chronic care management (CCM) refers to the chronic care services provided to Medicare beneficiaries with more than one chronic condition. Services include not only in person, face-to-face visits but also communication and the coordination of care related to the chronic conditions that a patient faces.

Chronic care management involves a comprehensive care plan that includes:

The comprehensive care plan explains to a patient the details and coordination of their care.

Recently, Medicare expanded to pay, in part or in full, for a patient’s CCM if they have two or more chronic conditions that are expected to last at least a year. 

Understanding Chronic Care Management

Patients who are eligible for a chronic care management program may have multiple (at least two) chronic conditions like (but are not limited to) Alzheimer’s disease, dementia, arthritis, asthma, autism, cancer, heart disease, depression, diabetes, multiple sclerosis, lupus, high blood pressure, hypertension, and/or infectious diseases like HIV/AIDS.

Chronic care management provides services that are outside of face-to-face patient visits. One of the most important aspects is a comprehensive and extensive electronic health record. This record includes the patient’s conditions, medications, allergies, medical history, demographics, and past care providers. Many patients who have chronic conditions see multiple care providers; a detailed electronic record is essential to facilitate optimum care. 

Chronic care management places a focus on a continuous relationship with a designated member of the patient’s care team. Ideally, the patient with chronic conditions feels supported enough to achieve their health goals. In a chronic care management program, a patient has 24/7 access to their care plan and health information and may contact their care team no matter the time or day of the week. The patient may contact the caregiver by telephone or through a secure electronic patient portal.

Goals of Chronic Care Management

People with multiple chronic conditions are at an increased risk for poor quality of life. The overarching goal of chronic care management is to help patients achieve a better quality of life through continuous care and management of their conditions. In a chronic care management 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. 

In the United States, the Office of the Assistant Secretary for Health reports that approximately 1 in 4 adults, 1 in 15 children, and 3 out of 4 seniors have multiple chronic conditions.

A goal of the healthcare system in chronic care management is to support patient self-care. CCM places more emphasis on individual behavior and a person’s responsibility in managing their health more effectively and independently. Patients with chronic conditions play an essential role in monitoring their health and any changes in it. 

Patients should be educated on the benefits of their treatment and motivated to comply with their treatment regimen. Research shows that patients involved in decisions about their care experience better health outcomes. Obviously, in many cases, the patient’s desire is a cure. A more realistic goal for a condition like say, diabetes, is an improved state and quality of life while living with the disease.  An ideal model for care of those with multiple chronic conditions is a collaboration between engaged patients and coordinated medical professionals. 

The Major Challenges of Chronic Care Management

Research has shown, however, that patients who are very sick tend to be less engaged in their care. A lack of engagement prevents patients from being able to manage their health.  Therefore, a focus on self-care and self-management is more appropriate when a person’s conditions and circumstances allow them to self-manage their health.

Both patient and medical care provider face many challenges in chronic care management. As the number of chronic conditions increases in a person, the risk of mortality, hospitalization, and medication interaction increases. Multiple chronic conditions directly contribute to disability. Patients with multiple chronic conditions usually require more extended, more in-depth, and more frequent doctor’s visits than is typical for acute care. Careful coordination of medical professionals is needed as well, or else fragmentation of care is a risk. Patients with multiple chronic conditions have a higher chance of receiving conflicting advice from their health care providers. Frequently, treatments for chronic conditions and diseases are complicated, making it difficult for patients to comply with the treatment protocol. 

Increased spending on chronic disease among Medicare beneficiaries is a key factor in driving the overall increase in spending in the Medicare program.

In American healthcare, chronic care management is exceptionally costly, accounting for 66% of the total health care spending. Two out of three Medicare beneficiaries have multiple chronic conditions. Not to mention, patients with multiple chronic conditions can experience substantial out-of-pocket costs, including astronomical prices for prescription drugs. Although Medicare has recently started paying for chronic care management services, it has been challenging to receive reimbursement for such services before the change. 

There are also challenges in chronic care management due to geographic distribution in disease. Chronic conditions like diabetes, obesity, and heart disease are more widespread in the southeastern United States than compared to the rest of the country. However, the prevalence of chronic conditions and the cost of treating are not always a linear relationship. For example, 16% of Texans have heart disease, and it costs an average of $23,000 per Medicare beneficiary per year to treat them. However, only 10% of residents in Maine have heart disease, yet the state spends almost $24,000 per recipient with heart disease. In Michigan, a patient with diabetes costs about $16,000 per year to treat, while in New Mexico, the cost is only $13,000. 

There are troubling racial, ethnic, and gender disparities in health care, including the rate of mortality and outcome of surgeries. Research has indicated that non-white patients have a 33% higher chance of death after undergoing heart surgery like a coronary artery bypass graft. Another study found that women were two times less likely to be screened for Hepatitis C than men. The same research found that Carribean Islanders had a significantly lower predicted probability of being tested for the virus than compared to other ethnicities. Studies have shown that in colorectal cancer, non-white patients have suffered disproportionately worse outcomes and higher mortality rates than white patients. Differences in the receipt and location of appropriate care may also predict survival after treatment for colorectal cancer.

The Evolution of Chronic Care Management

Chronic care management is a relatively new branch of medicine. Beginning in the 1980s, members of the medical community began to try to understand and research chronic care and its phases and stages. Since then, there has been a significant effort in the development of treatments and research on understanding the physical and psychological effects on people suffering from chronic illnesses.

Chronic diseases affect approximately 133 million Americans or 40% of the total population of this country. By 2020, it is projected that the number will reach 157 million, with 81 million of those people having multiple conditions. 

The supply and distribution of primary care health professionals will be insufficient to meet the needs of the growth in chronically ill patients. Increasing the role of registered nurses and recruiting more people into nursing may be part of the solution to the demand placed on health care as the number of people with chronic conditions increases.

As the number of Americans with chronic condition grows, so does the demand for chronic care management software.

What’s in the Chronic Care Management Model?

The chronic care model, developed by the MacColl Center for Healthcare Innovation, aims to improve the deficiencies of chronic care management today. Some deficiencies include practitioners who do not follow established practice guidelines, a lack of coordination between care providers and follow-up with the patient, and inadequate training of patient self-management.

The chronic care model aims to reform and strengthen the Health System, Delivery System, Decision Support, Clinical information systems, Self-management Support, and Community resources. With these reformed systems, an informed patient, and a prepared care team, there will be improved outcomes. 

Chronic Care Management in Medicare

Medicare & Medicaid Services (CMS) now recognizes chronic care management as a critical factor in primary healthcare, and a necessary component to improve the health of Americans. 

In 2015, Medicare began paying under the Medicare Physician Fee Schedule for chronic care management services, including non-face-to-face coordination services for Medicare beneficiaries with at least two chronic conditions. 

Under Medicare, a comprehensive care plan for all health issues typically includes, but is not limited to: 

In 2017, there were 58 million Medicare beneficiaries in the United States. Two out of three Medicare recipients have multiple chronic conditions. 

Only physicians, certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants may bill Medicare for chronic care management services.


RevUp is a chronic care management service that can be used with athenaPractice to assemble a patient’s CCM care plan and make it available securely anytime, anywhere. RevUp can help provide cost effective, high touch care that allows your practice to benefit from fee-for-service reimbursement today, while preparing for value-based reimbursement models in the future.

RevUp includes a smart phone application and internet portal that support patient engagement. Patient data is acquired through modalities including the RevUp mobile and web applications, monitoring devices, fitness trackers, and telephonic communication. This collected data is integrated into athenaPractice to provide a comprehensive view of the patient’s health between office visits to support a high touch care model and enable new provider insights.

Interested in learning more? Experience how RevUp can help your patients best.

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