Chronic Care Management (CCM) refers to the coordination of care services provided outside of normal office visits. Individuals suffering from two or more chronic diseases have less than a year or till death—and time has finally spoken. 

In 2015, Chronic Care Management (CCM) was acknowledged as an essential component of primary care by the Centers for Medicare & Medicaid Services (CMS). The Centers greatly believe that integrating chronic care will improve the health of the elderly in particular. 

With this specific age group, multiple hospitalizations, expensive medical treatment, and follow-up are all common in a wide range of conditions. Patient activities can either enhance or stop the patient’s decrease in quality of life.

The Chronic Disease Management Plan addresses the following chronic diseases:

  • Addictions
  • Alzheimer’s
  • Arthritis
  • Asthma
  • Atrial Fibrillation
  • Autism
  • Cancer
  • Cardiovascular Disease
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Diabetes
  • Hypertension
  • Infectious Diseases
  • Obesity
  • Stroke/Neurological Condition

Such chronic illnesses are the leading causes of mortality and disability in the United States. Because of this, medicare beneficiaries are being targeted because they account for a large part of healthcare expenses. 

Fortunately, there are several ways to enhance preventative care. In incorporating patients more entirely into their treatment regimens, chronic illnesses need extensive in-office care and follow-up. It is also feasible to strengthen the doctor-patient connection without increasing the frequency of doctor-patient contacts. 

Activities for Chronic Care Management

A medical practice’s CCM strategy may include various activities that contribute to the required monthly service time, such as:


  • Patient Communication Techniques

In addition to in-person consultations, staff can communicate with chronic care patients regularly. These messages would address patient health concerns, test reminders, medical record checks, and self-care advice. As needed, other health care providers would be informed of the patient’s medical history.


  • Conduct Patient Data Exchange

Giving all health care practitioners access to a patient’s complete medical history is a time-consuming and inefficient procedure. It is possible to eliminate redundant testing and unnecessary medications or treatments with greater upfront information exchange.


  • Increased Care Transition Levels

When patients seek therapy for a chronic illness, they are transferred from home to hospital to treatment center and back home. Clinicians frequently supplement or alter current medication regimens, requesting medical and prescription information from patients or their families at every level. More thorough medical histories and enhanced follow-up for discharged patients can help with transitional care management.


  • Administration of Medication

Individuals with many chronic diseases frequently consult with various medical professionals to rule out allergic reactions, overdoses, and drug combinations.


  • Improved Residential Care

A wide range of nursing and therapeutic care can be provided at home if the primary provider is aware of, permits, and documents these actions. Any changes in appearance or weight should be reported to the medical facility for further evaluation.

The doctor may then create a complete assessment and treatment plan for the chronic care patient, considering all medical, psychological, and underlying chronic problems. To encourage patient engagement, this information must be shared with the patient. 

The provider may also employ personal care workers, visiting nurses, food suppliers, or childcare services to achieve the plan’s objectives.

Benefits of Chronic Care Management

While most medical professionals enter the field to help patients live happier and healthier lives, administrative chores may occasionally distract their attention away from patient care. CCM shifts focus back to population health care. These are the benefits of CCM:

  • Superior Outcomes: The goal of each practice is to improve patient care coordination and engagement.


  • Reimbursement: Patients receive 20 minutes of CCM services once a month.


  • Patients’ Involvement: Patients encouraged to use CCM services are more likely to maintain healthy lifestyle behaviors in the interim between clinic appointments.


  • Improved Compliance: Patients feel more empowered to make beneficial health changes with the help of their doctor.


  • Increased Satisfaction: Increased office efficiency leads to higher patient satisfaction.


  • Reduced Emergency Room Care: When people manage their chronic illnesses, insurance companies save money.


  • Revenue Protection: CCM allows you to grow your business without adding new buildings or staff and assisting patients in need while allowing doctors to care for the rest of their patients.


Before anything, you and your loved ones must understand the significance of Chronic Care Management. After all, it’s only for improving one’s quality of life, especially once they experience symptoms of health decline. At the same time, having a clear understanding of this medical method may smooth communication between patients, clinicians, and families involved.

Are you in need of chronic care management? Medistics Heath offers remote monitoring and patient care that tackles all types of physical, chronic, and behavioral health conditions. We’re here to give you a simplified yet effective service to give you a better life through our humanized healthcare approach. Get in touch with us today!

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