Chronic Care Management Service

Increase practice revenue and improve care outcomes for your chronic patient population


What is Chronic Care Management? Why is it Important?

Chronic conditions are long-term health problems such as diabetes mellitus, cardiovascular disease, allergies, asthma, and anxiety disorders. About one third of the total population are affected by multiple chronic conditions, which can be costly to maintain over time.

Patients with chronic conditions account for the majority of all primary care visits and over 90 percent of all Medicare spending goes toward treating people with chronic conditions. Patients with multiple chronic conditions are also a major cause of hospitalization: 70 percent of all inpatient stays are for people with two or more chronic conditions.

Healthcare systems could be doing a better job managing chronic care patients. Improving the health of these patients could lead to the prevention of secondary complications of disease and a reduction in emergency room visits, hospitalizations, and readmissions. Primary care practices became de facto care coordinators for patients with multiple chronic conditions; hence, Medicare and other HMO’s started Chronic Care Management (CCM) programs as a new option to help engage and manage such patients between office visits.

Option Available to Physicians - Chronic Care Management (CCM) Program

A recent study showed nearly half of Medicare patients readmitted to hospitals within 30 days for problems arising from their diagnosed condition had no post-discharge contact with healthcare professionals. Patients with multiple chronic conditions have better outcomes when they are given tools to promote better self-care and have a skilled resource to help coordinate care between multiple providers.

Patients also receive better continuity of care when a practice develops a holistic view of the patient’s needs to include their functional, social, physical, and mental health and also provides a point of regular contact for the patient. Chronic Care Management (CCM) services addresses this gap in care by providing management of patients between office visits.

Chronic Care Management assists in care coordination by:

  • Offering communication, engagement and monitoring of patients by a team of clinical staff consisting of RNs, LPNs and CMAs
  • Assisting and encouraging patients to follow physician-approved care plans based on physician-provided diagnostic codes and additional patient input 
  • Helping to meet CMS requirements for the chronic care management CPT code reimbursements (CPT 99490), including monthly non-face-to-face patient contact
  • Ensuring physicians are current with care plan updates so practices can better predict and prepare for the next office visit
  • Discussing, directing and assisting patients with socio-economic requirements when needed
  • Conducting periodic medication reconciliation and assistance to patients with refill requirements; review of adherence and potential interactions; document and update any OTC medication consumed
  • Offering 24/7 access to clinical staff and providing patients and care givers, as appropriate, with the means to make contact with clinical staff in case of emergency
  • Ensuring continuity of care through clinical staff to schedule appointments for follow up visits
  • Oversight of patient self-management of medications

Simple Actions = Big Positive Effects

Greater vigilance of patients with chronic conditions does not have to be difficult and can be a key to healthier outcomes and lower healthcare costs. In addition, these “care beyond the walls” programs in the home or outpatient settings can not only help delay or prevent complications and costly interventions but can also improve a practice’s performance under the Medicare Access and CHIP Authorization Act (MACRA).  

MACRA requires demonstrated effort in improving quality of care (the Quality score) as well as coordination of care (the Clinical Practice Improvement Activities score). Availing your practice of solutions, such as Chronic Care Management programs that address social or economic issues and engage in care management between visits, can reap dividends for your patients, practice and payers. 


Chronic Conditions

There are more than 50 chronic conditions eligible for CCM Services.  Broad categories of most common chronic conditions are as follows:

  • Addiction/substance abuse: Alcoholism, Opiate abuse
  • Autoimmune diseases: Osteoarthritis, Rheumatoid arthritis
  • Blood disorders: Anemia, Leukemia
  • Cancer: Breast cancer Colorectal cancer Prostate cancer
  • Cardio-metabolic conditions: Congestive heart failure, Diabetes, Dyslipidemia
  • Chronic pain Resulting from diseases in various therapeutic areas, e.g., autoimmune diseases, cancer
  • Endocrine disorders Addison’s disease Hypothyroidism
  • Eye conditions: Cataract, Glaucoma
  • Gastrointestinal diseases: Crohn’s disease, Gastroesophageal reflux disease
  • Infectious diseases: Hepatitis C, HIV
  • Kidney diseases: Chronic kidney disease, End-stage renal disease
  • Lung diseases: Asthma, Chronic obstructive pulmonary disease, Emphysema
  • Mental disorders: Bipolar disorder, Depression
  • Neurological diseases: Alzheimer’s disease, Multiple sclerosis
  • Urologic diseases: Benign prostatic hyperplasia, Interstitial Cystitis

Let's Talk!

To learn more about how Harris Ambulatory Group’s solutions can help your practice, reach out to us today.