The Chronic Care Management (CCM) program provides care coordination services outside regular in-office health visits for patients with multiple chronic conditions. This program allows healthcare providers, clinical specialists, and physician’s assistants to bill for at least 20 minutes of care coordination services per month. 

If you’re looking to implement a chronic care management program, you need to plan and analyze its features and functionalities carefully. Here are six of the best features to enforce:

1. Confidentiality

Your chronic care management program needs to have the right security standards that protect your patients’ health information. All activities related to the CCM program should comply with the Health Insurance Portability and Accountability Act (HIPAA). These compliance measures are necessary to protect patient health information at all times.

2. Compliance

CCM services must ensure a detailed level of compliance as required by the Centers for Medicare and Medicaid Services (CMS). In addition, any employee involved with the program must be effectively trained and understand the rules to follow.

Regular quality audits also need to be conducted to ensure that documentation and phone calls abide by the guidelines set in place for CCM programs.

3. Clinical Interoperability

Your chronic care management program must have a clean integration with your electronic health record (EHR). That allows patient care plans to be stored within the EHR and the smooth flow of di-directional data. The same thing goes for clinical and billing data. The most important thing to ensure is that your CCM program can be integrated with your own EHR. 

4. Clinical Care Team

Your care team is at the heart of your CCM program because they perform care coordination for your patients. Their job is to advance your patients’ clinical outcomes, improve their health for the better, and reduce readmissions and hospitalizations. Care team clinicians are generally responsible for tending to enrolled beneficiaries and managing their chronic diseases through quality preventative care. 

5. Patient Marketing

Patient marketing is an essential tool that educates and improves patient management. Your patients are unlikely to understand the program’s benefits if you don’t create the right marketing efforts. In turn, that will lead them to decline your offer for enrollment. 

But even after enrollment, patients need to be constantly reminded of their benefits and how they can best utilize the program. 

6. CCM Program Enrollment

Your CCM services must have an enrollment feature as one of their key drivers to success. Having a team of trained experts who call your eligible beneficiaries with chronic conditions, explain the program’s benefits, and encourage them to enroll can take some work off you. 

This team of experts is skilled in marketing strategies that will lead you to have high enrollment rates. Without this particular skill set, you might be looking at a smaller CCM patient population. 


These are only some things you need to evaluate before you create your own chronic care program. Moreover, you should also be ready to provide continuous training and support to your care team, who facilitate almost all processes relating to your patients’ health. They need to be fully trained before your program’s launch to ensure success.

Medistics Health humanizes healthcare with remote patient monitoring. We believe that healthcare does not begin and end in the four corners of a doctor’s office. Instead, it is a concentrated, organized, continuous process that adapts to the needs of every individual patient. We are committed to providing patient-centered care always. Get in touch with us today!

Profit Calculator Assumptions: 40% of total Medicare patients enrolling is based on (i) Medicare Chart Book’s data showing that ~68% of medicare patients qualify for CCM (2 or more chronic conditions), and (ii) that ~40% of eligible patients will enroll.

For typical providers, $46.67 of net profit per patient per month is based on a Medicare reimbursement per patient per month (national average) for various care management CPT codes.

CPT and other codes, descriptions and other data are copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).