Five Things to Know about Deploying Chronic Care Management in 2021

The COVID-19 pandemic has driven home for me—as both a consultant and weekend gerontological practitioner—the vulnerabilities of older adults, especially those with chronic health issues. As an adult child with an aging parent, I understand the importance of concierge support for older patients. Fortunately, healthcare providers can leverage the Centers for Medicare & Medicaid Services’ (CMS) Chronic Care Management (CCM) program to coordinate the care needs of both high-risk and at-risk patients using existing staff.

CCM helps patients achieve improved quality of life through ongoing care coordination and self-management of at least two or more chronic conditions. My practice has tapped into CCM on a small scale for high-risk patients since 2015, and the pandemic created impetus to expand services to at-risk patients who would also benefit.

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I have seen firsthand that benefits of CCM include reduction in pain and frequency of acute disease exacerbations; improvement in depression, anxiety, stress, and weight with increased physical activity; ambulatory stability; and overall enhanced well-being.

Healthcare leaders should keep in mind five key areas as they consider implementing CCM:

1. Use multiple avenues to stay in touch with patients. High-risk and at-risk patients do not need added exposure to any virus by leaving their homes, but require their chronic condition to be monitored, whether it is lung disease, cardiovascular, or neurological, such as dementia. CCM allows five to ten weekly or biweekly outreaches via phone, email, and/or text to connect with patient/family, in addition to scheduled office visits, helping providers stay current with patients’ status and changing social circumstances.
2. The benefits outweigh objections. My practice has addressed patient reluctance upfront. Some patients felt CCM should be part of usual practice service, despite the reality that it had not been for years within the context of our typical office processes. Others did not want someone “messing” in their personal life. After a few CCM contacts, my patients experienced the value of having their “own nurse” whom they could call with questions or concerns, who in turn provided additional education, coaching, and intervention within the context of their diseases and social situations. Patients’ families expressed having an “overwhelming burden removed” in knowing that our practice was reaching out proactively to check on their loved ones during a national public health emergency.
3. CCM can help your bottom line. My goal was to provide this service without running a deficit. CMS provides a monthly reimbursement for the CCM support to patients between their usual office visits. The CCM support was conducted efficiently in the form of monitoring outreach, education on disease and self-management, medication evaluation and refills, referrals for both health and community services, lab, and imaging requests. Coding was based on the complexity and time spent with each patient and ranged between $42 and $100 per patient per month. Our CCM caseload initially capped at 120 patients, as we limited the medical assistant’s time to twenty hours per week when we launched the program. As demand grew, we expanded to 243 patients with increased hours. Although initially the setup was time intensive, we leveraged technology to support education, self-management, and documentation. With initial part-time dedication to CCM, revenue after six months generated almost $5,000 per month. As we ramped up with the pandemic, revenue doubled. On occasion, CCM outreach necessitated a separate same-day telehealth visit with the provider, yielding early assessment and intervention in a patient’s health that prevented a later trip to the office or emergency room. These visits were reimbursed under CMS telehealth codes.
4. CCM can lead to greater patient satisfaction and quality of care. As we worked to close gaps in care, promote enhanced quality, and increase communication among staff, we saw an increase in patient satisfaction. This in turn supported value-based agreements with additional incentives achieved.
5. CCM can increase staff satisfaction. CCM yielded a deeper sense of contribution to patients than staff roles previously allowed and created a sense of knowing that as a team we were all “taking good care of our patients.” This boosted staff retention and role expansion. This expansion, aided through internal staff education and policies to support telephone triage and critical thinking, will continue through the pandemic and flu season, and into the future.

My goal as a provider has been to take good care of my patients and help them beyond the office walls, without losing money. When we implemented CCM several years ago, the goal was to break even. In realizing a profit, our small community practice has been able to expand and provide downstream support within the clinic. But the biggest benefit of all—creating value for both staff and patients—remains priceless.