The Smart Medical Practice

Chronic Care Management & Better Care Coordination


Chronic Care Management

Care Coordination (Part 2)

In our last post, we dove into the details of CMS’s Chronic Care Management (CCM) program, which pays providers to deliver coordinated care to Medicare and dual-eligible patients with two or more chronic conditions. In this post, we’ll look at all the benefits to patients and providers.

First and foremost, this program helps providers get paid for care management work they may not have billed for in the past.

Additional benefits include:

  • More comprehensive care. By focusing on managing chronic conditions, providers will ensure these patients receive all recommended preventive services. Care will focus on both medical and psychosocial issues.
  • Person-centered care. Through developing and sharing a care plan, clinicians will provide care more tailored to the individual.
  • More engaged patients. The development of the care plan will help to both educate and engage the patient.
  • More inclusive care. Providers will work with home- and community-based clinical service providers as needed. They’ll also reconcile their medication list with medications prescribed by other providers.
  • Better care transitions. Providers will share information with other providers to ensure referrals and discharges are smooth and will follow up in a timely manner after a facility stay or referral.
  • Improved record keeping. Core health information for CCM patients will be recorded in a certified EHR.

Benefits to patients

There are a number of significant benefits to patients from this program:

  • Receiving a comprehensive care plan will help support their disease control and health management goals.
  • Better health outcomes will result from having help with treatments, medications, referrals, and appointments.
  • 24/7 access to a qualified healthcare professional will help them address urgent needs.
  • Enhanced communication methods, such as a secure email portal, will help patients feel more connected.
  • Improved management of care transitions, referrals, and follow-ups will ease transitions.
  • A more holistic approach to care that includes psycho-social, functional, and environmental factors in addition to physical, mental, and cognitive goals will improve health outcomes.

With two-thirds of people on Medicare having two or more chronic conditions, there’s little question the CCM program can benefit both providers and patients. We’ll have more coverage on this important topic in the coming months.

Additional Resources:

Chronic Conditions Among Medicare Beneficiaries
Chronic Care Management Services Fact Sheet
FAQs About Physician Billing for Chronic Care Management Services


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