What is Chronic Care Management?

Chronic Care Management (CCM) is a Medicare-supported program designed to help individuals with multiple chronic conditions better manage their health. The program provides ongoing care coordination, improving health outcomes and reducing the need for emergency care or hospitalizations.

Chronic Care Management involves coordinated care for patients with two or more chronic conditions expected to last at least 12 months (or until the patient’s death) and that place the patient at significant risk of decline or complications. Conditions can include diabetes, hypertension, heart disease, asthma, arthritis, and more.

What Does Chronic Care Management Cover?

CCM typically covers:

1. Care Coordination: Ensures communication between healthcare providers, specialists, and other services.
2. Creation of a Comprehensive Care Plan: Outlines the patient’s medical conditions, goals, medications, and treatments.
3. Medication Management: Helps patients understand and adhere to their prescribed medications.
4. 24/7 Access to Care: Provides access to healthcare professionals who can address urgent needs.
5. Regular Follow-Up: Includes monthly check-ins to monitor and adjust care plans as needed.
6. Referrals: Coordinates referrals to specialists or community services.

What Does It Entail?

• Enrollment: Patients must give consent to participate in the program, typically during a conversation with their primary care physician.
• Monthly Services: Patients receive at least 20 minutes of non-face-to-face care each month, often via phone or electronic communication.
• Team-Based Approach: Care is provided by a team, which may include doctors, nurses, and care coordinators.
• Comprehensive Care Plan: As your primary care physician understands your conditions and unique situations, they will create, revise, and monitor a personalized care plan. This plan will be based on your physical, mental, cognitive, psychosocial, functional, and environmental capabilities, while also taking into account resources and support on-hand. 

Who Can Help?

1. Primary Care Providers (PCPs) are the central point for CCM. They develop care plans and coordinate services within the care team.
2. Specialists may collaborate with the PCP to address specific conditions.
3. Nurses and Care Managers often handle day-to-day coordination, patient education, and follow-up.
4. Pharmacists assist with medication management and adherence.

Benefits of Chronic Care Management

• Better health outcomes through proactive care.
• Reduced hospitalizations and emergency visits.
• Improved medication adherence.
• Enhanced patient education and self-management.
• Greater continuity of care.

CCM is primarily available to Medicare beneficiaries, but some private insurers may also offer similar programs. If you or a loved one could benefit, contacting your primary care physician is an excellent first step. They can assess eligibility and explain how the program works in your specific case.