How to Start a Chronic Care Management Program: A Step-by-Step Guide for Healthcare Providers

Jon-Michial Carter

Written by Jon-Michial Carter

Chronic Care Management (CCM) programs, introduced by the Centers for Medicare and Medicaid Services (CMS) in 2015, represent a significant shift towards value-based care. These programs incentivize healthcare providers to extend comprehensive care to patients with multiple chronic conditions beyond the confines of traditional office visits. By adopting CCM, healthcare practices can unlock new, recurring revenue streams while simultaneously elevating the quality of patient care. CCM empowers eligible patients to receive a holistic, patient-centered approach to managing their chronic illnesses, leading to improved health outcomes, reduced hospital readmission rates, lower overall healthcare costs, and crucial support in navigating socioeconomic barriers to care.

However, the path to implementing a successful CCM program can appear daunting for many healthcare practices. Already grappling with demanding schedules, limited resources, and stretched staff, the prospect of independently establishing a CCM initiative can feel overwhelming. From patient education and enrollment to maintaining consistent monthly patient contact and ensuring strict CMS compliance, the perceived burdens, coupled with potential upfront costs, often explain why CCM remains surprisingly underutilized, despite its well-documented clinical and financial advantages.

This comprehensive guide aims to demystify the process of starting a chronic care management program. We will provide expert insights into every critical facet, from effective patient engagement strategies to streamlined clinical workflows and the complexities of enrollment management. Furthermore, we will explore the strategic advantages of partnering with a full-service CCM provider like ChartSpan, highlighting how such collaborations can significantly alleviate the administrative and operational workload, enabling your practice to fully realize the numerous benefits of CCM without straining your valuable resources and time.

10 Essential Steps to Launch Your Chronic Care Management Program

CCM programs present an exceptional opportunity for healthcare practices to diversify revenue streams while delivering enhanced care to patients managing chronic illnesses. However, launching a thriving CCM program necessitates meticulous preparation and strategic planning. Without a structured approach, your CCM initiative may face significant hurdles. Here are ten crucial steps to guide you in establishing a robust and effective chronic care management program:

1. Thoroughly Evaluate CCM Program Requirements and CMS Guidelines

While a well-executed CCM program can yield transformative results for both your practice and your patients, it’s essential to acknowledge the inherent complexities of program management. Before committing to an in-house CCM program, a comprehensive understanding of the detailed requirements is paramount. Healthcare providers must be prepared to adapt internal strategies as CMS continuously updates and refines program guidelines. A proactive and thorough grasp of these demands from the outset is crucial to mitigate the risk of unforeseen responsibilities and documentation burdens. These encompass meticulous time logs, diligent tracking of care plan modifications, seamless communication protocols with all involved care providers, and detailed records of every patient and caregiver interaction.

Operating a CCM program internally necessitates the establishment of a 24/7/365 care line, a significant undertaking in itself. Your existing staff will likely need to assume the role of CCM care managers, requiring them to conduct a substantial volume of monthly patient outreach calls, alongside managing subsequent care coordination tasks. These responsibilities include, but are not limited to, updating patient care plans and goals, facilitating medication refills, and arranging necessary transportation. Furthermore, your practice will bear the full responsibility for maintaining rigorous compliance standards and meticulous billing records. You may need to consider hiring and training additional personnel to effectively handle this significant influx of workload.

Successfully obtaining CMS reimbursements hinges on meticulous documentation of patient health information and the comprehensive care management services provided to each participant. Your practice must also possess a thorough understanding of CMS’s intricate billing requirements, diligently verify patient eligibility criteria, and ensure sufficient staffing levels to consistently perform the required care coordination and maintain mandated monthly communication. These are just a subset of the critical considerations a practice must address when embarking on establishing a comprehensive CCM program.

Learn more about the fundamentals: Chronic Care Management: Benefits, Requirements, & Reimbursements for Providers

2. Assess Resources, Infrastructure, and Workflow Adaptations for CCM Operations

Prior to the official launch of your CCM program, a critical internal assessment is required to evaluate the existing resources, identify staffing needs, optimize current workflows, and address any infrastructural adaptations necessary to support CCM operations.

Your practice’s infrastructure must be adequately equipped to meet the demands of a CCM program. Depending on the projected scale of your initiative, strategic investments in technological upgrades may be necessary. This could include enhancing your telephonic systems to manage both outbound patient check-in calls and inbound care line inquiries efficiently. Developing a robust strategy to automate and standardize workflows is also essential to ensure consistent compliance and operational efficiency across all CCM activities.

Partnering with a specialized CCM company, such as ChartSpan, can significantly reduce the need for extensive new staff recruitment. However, your existing staff will still play a vital role in the process. Their responsibilities will include reviewing patient eligibility lists provided by the CCM partner, carefully reviewing patient care plans and goals developed in collaboration with the CCM team, and effectively managing CCM clinical notifications originating from the CCM partner’s nurses, who operate under the general supervision of your practice’s physicians.

Identifying an internal champion to spearhead the CCM implementation efforts is also of paramount importance. Even with the support of a CCM partner, a designated internal leader is crucial for coordinating implementation activities. This individual will be responsible for attending crucial meetings, promptly responding to communications, establishing project timelines, and providing necessary approvals throughout the implementation process.

CCM programs are most effective when they can operate seamlessly and at scale. Achieving this level of scalability can be challenging for individual practices due to limitations in available staff, time, and internal resources. A CCM partner like ChartSpan offers a solution to this challenge by providing the infrastructure and dedicated staff necessary to scale your program effortlessly. Our team is well-versed in meeting CMS requirements and is dedicated to maximizing patient enrollment and enhancing the overall patient experience.

3. Rigorously Review Patient Eligibility for CCM

Before fully implementing a CCM program, a crucial initial step is to accurately assess the number of eligible patients within your practice to ensure the initiative is justified and sustainable. CCM eligibility extends to all Medicare Part B beneficiaries who are diagnosed with two or more qualifying chronic conditions. These conditions must be expected to persist for at least twelve months or until the patient’s end of life.

For practices managing their CCM program independently, a detailed analysis of your Electronic Health Records (EHR) is necessary to compile a comprehensive list of potentially eligible patients. Patients with conditions such as COPD, diabetes, hypertension, or behavioral health conditions frequently meet the eligibility criteria for CCM.

Approximately 82% of Medicare beneficiaries are estimated to qualify for CCM services, making it a particularly relevant and beneficial program for practices with a significant patient base over the age of 65. CCM can be especially advantageous for specialists such as cardiologists, nephrologists, and urologists, who often serve a higher proportion of elderly patients with multiple chronic illnesses.

Patient eligibility for CCM is not static; it’s an ongoing process. Patients continuously become eligible as they enroll in Medicare or receive diagnoses for additional chronic conditions. Conversely, patients may become ineligible for CCM if they transition to full-time assisted living facilities or pass away.

Practices managing their CCM programs in-house are responsible for the continuous task of extracting and evaluating updated patient eligibility lists from their EHR systems. By partnering with a CCM company, this administrative burden can be significantly reduced. A CCM partner can regularly generate and update patient eligibility lists and provide them to your providers for efficient review and approval, adhering to CMS guidelines.

4. Implement Robust Patient Education and Enrollment Strategies

Patient enrollment is a cornerstone of a successful and financially sustainable CCM program. Patients are more likely to enroll and actively participate when they have a clear understanding of Chronic Care Management and the substantial value it offers to their healthcare journey. Therefore, all providers, clinical staff members, and any collaborating CCM partners should be well-equipped to effectively educate patients about CCM.

The patient enrollment process can be logically divided into three key stages: pre-enrollment education initiatives, the formal enrollment process itself, and the post-enrollment onboarding and welcome phase.

Pre-Enrollment Patient Education:

Prior to initiating patient enrollment, your practice should launch a comprehensive education campaign to raise awareness and understanding of CCM. This can be achieved through various channels, including direct in-person communication, targeted phone calls, direct mail campaigns, and informative printed materials prominently displayed in your office and waiting areas. Your practice plays a pivotal role in introducing CCM to your patient population, fostering trust in the program’s benefits, and generating patient enthusiasm for participation.

Utilize brochures, informative posters, and engaging slideshow presentations in your office to educate patients during scheduled appointments. Proactive outreach through text messages, personalized voicemails, and physical mailings can also be employed to familiarize eligible patients with the CCM program before formally requesting their consent to enroll.

When collaborating with a reputable CCM partner, they should provide support in crafting impactful educational messaging, leveraging industry-proven informational language that resonates with patients. CCM partners can also offer training to your internal staff on effectively communicating the benefits of CCM, ensuring they feel confident and knowledgeable when discussing the program with patients. Furthermore, they can provide pre-designed emails, recorded voicemail scripts, phone call templates, direct mailers, and printed marketing materials to support your patient education efforts.

The Patient Enrollment Process:

Following the patient education phase, the next step is to formally seek patient consent and facilitate enrollment in the CCM program. Typical patient enrollment calls often include the following key elements:

Patient Identity Verification: Confirming the patient’s identity to ensure privacy and security.
Comprehensive Explanation of CCM Benefits: Clearly articulating the numerous advantages of CCM for the patient’s health and well-being.
Highlighting Unique CCM Features: Detailing specific program components such as monthly check-ins, personalized care plans, coordinated care services, and 24/7/365 access to a dedicated care line.
Transparent Discussion of Costs: Explaining that while Medicare covers CCM services, standard deductibles and copays may apply.
Clarifying Enrollment Terms: Ensuring patients understand they can unenroll at any time and can only be enrolled in CCM under one provider at a given time.
Obtaining Explicit Patient Consent: Directly asking the patient if they wish to enroll in the CCM program.
Call Recording and Archiving: Recording and securely archiving enrollment calls for compliance and quality assurance purposes, typically for a minimum of 10 years as recommended by best practices.

Patients must explicitly verbally consent to enroll in CCM before they can be formally enrolled in the program. While some clinical staff may be comfortable conducting patient enrollment calls, many practices prefer to utilize trained enrollment specialists from a CCM company to manage this critical process. Enrollment specialists possess specialized expertise in CCM program details and are adept at addressing patient inquiries and concerns. They also have the dedicated time and focus required for effective enrollment outreach, allowing clinical staff to concentrate on their primary patient care responsibilities. ChartSpan’s team of skilled enrollment specialists achieves an average enrollment rate of 45%, demonstrating their effectiveness.

An effective CCM partner will also leverage patient insurance and demographic data to provide accurate estimates of patient co-pays, ensuring transparent communication of financial obligations to the patient during the enrollment process.

Post-Enrollment Patient Welcome and Onboarding:

Even after successful enrollment in a CCM program, patients may still have lingering questions or require further clarification about the program’s details. A well-designed CCM program will provide comprehensive materials to address these needs and ensure a smooth onboarding experience. ChartSpan, for example, provides patients with a welcome packet containing detailed information about CCM services, frequently asked questions, and essential contact information for their assigned care managers and the 24/7 care line. Furthermore, newly enrolled patients receive a personalized welcome call from their dedicated care manager, establishing a personal connection and addressing any immediate questions.

Ensuring patients feel welcomed, well-informed, and supported immediately after joining the program is crucial for building trust and establishing a strong foundation for a successful and long-term patient-provider partnership within the CCM framework.

5. Develop Proactive Continuous Patient Engagement Plans

For practices without a CCM partner, developing and implementing robust strategies to maintain high levels of patient engagement is essential for program success. Patient engagement is not a one-time event; it requires ongoing efforts to keep patients actively involved, informed, and supported throughout their CCM journey. Sustained engagement is crucial for achieving improved clinical outcomes and contributes directly to the long-term success and high enrollment levels of your CCM program.

Dedicated care managers play a vital role in continuous patient engagement. They can achieve this through various proactive measures, such as sharing personalized dietary and exercise plans, regularly checking in on patient progress and adherence to wellness plans, and proactively providing resources to address Social Determinants of Health (SDOHs), which significantly impact patient health outcomes. These SDOH resources can include assistance with transportation, information on available financial aid programs, and suggestions for relevant community activities and support groups.

Your CCM program should also incorporate specific re-engagement strategies to address situations where patients become less responsive and stop answering monthly phone calls from their CCM care managers. Re-engagement efforts can include utilizing a multi-channel communication approach, such as leaving personalized voicemails, sending targeted text messages, and sending informative emails to re-establish contact and re-engage patients in the program. Partnering with an experienced CCM company like ChartSpan provides access to their wealth of expertise in patient engagement and proven strategies for effectively re-engaging disengaged patients, maximizing program effectiveness.

6. Strategically Plan the Patient’s Individualized Care Journey

Providing consistent and personalized support to each patient throughout their unique wellness journey is the fundamental principle underpinning every well-managed CCM program. Care managers should leverage personalized wellness plans, collaboratively defined care goals, and proactive preventive care strategies to promote positive clinical outcomes and optimize the overall quality of life for enrolled patients.

CCM care managers should be thoroughly trained to proactively identify potential gaps in care and actively assist patients in scheduling necessary appointments, recommended screenings, and vaccinations to effectively close these gaps. They should also be equipped to recognize early warning signs of loneliness, social isolation, and behavioral health challenges. Administering standardized depression screenings, such as PHQ-2 assessments, is a crucial component of proactive care management. Furthermore, care managers must be prepared to provide timely assistance to patients with medication refills, address transportation barriers, and connect them with essential food resources if they identify SDOH-related obstacles hindering a patient’s care journey.

ChartSpan utilizes SMART (Specific, Measurable, Achievable, Relevant, and Time-Based) goal-setting guidelines to empower patients to collaboratively create individualized care goals that align with their personal wellness aspirations and priorities. We have also developed a proprietary program called ChartMarkers designed to comprehensively assess patients’ conditions, systematically identify areas where they require additional support or focused care, and proactively intervene when necessary to optimize patient outcomes. Some of the key assessments we conduct as part of ChartMarkers include:

Comprehensive Clinical Assessments
Medication Adherence Assessments
Quality Assessments to Identify Care Gaps
Social Determinants of Health Assessments

Image alt text: ChartMarkers patient journey visualization showing clinical assessments, medication adherence, quality assessments, and SDOH assessments as key components of chronic care management.

7. Ensure Accurate Billing and Program Compliance Through Proper Coding

By consistently delivering value-based care to your patients with chronic conditions through a CCM program, your practice can access significant additional recurring revenue streams. To maximize these financial reimbursements and ensure financial sustainability, your clinical and administrative staff must possess a thorough understanding of the complex billing rules, specific service requirements, and relevant Current Procedural Terminology (CPT) codes associated with CCM.

Reimbursement for CCM services is based on the non-face-to-face care coordination services provided by your clinical staff or your CCM partner’s team. These services are billed to CMS on a monthly basis, and the specific CPT codes utilized will vary depending on the complexity of care provided and the total aggregated time spent delivering care coordination services throughout the month. Maintaining a meticulous and accurate record of all CCM care coordination services provided to each patient is absolutely essential for ensuring program compliance and accurate billing.

Therefore, ensuring proper billing practices represents another intricate and time-consuming aspect of CCM program management that many practices find challenging to implement effectively without external support. ChartSpan’s innovative RapidBill technology is designed to simplify this process, enabling your practice to easily review and accurately bill for CCM services each month. We handle the assembly of all necessary documentation and provide the appropriate CPT codes tailored to the services delivered. Your staff simply needs to review the pre-populated codes and submit the claim to CMS, streamlining the billing workflow and ensuring accuracy. With RapidBill, you can seamlessly integrate recurring revenue streams into your practice’s financial operations.

For in-depth billing information: Chronic Care Management CPT Codes & Billing Guide

8. Establish Seamless Clinical Alignment for Your CCM Program

Establishing streamlined clinical alignment is paramount to ensuring that your CCM program operates smoothly, reliably, and is fully integrated into your practice’s existing workflows. If you choose to partner with a CCM vendor, proactively defining how your practice will manage key operational tasks is crucial. These tasks include:

Efficiently pulling Consolidated-Clinical Document Architectures (C-CDAs) to gather essential patient eligibility data.
Establishing clear protocols for initiating communication regarding specific patient needs through timely and effective notifications.
Developing a well-defined system for triaging incoming calls and promptly sending notifications regarding patient emergencies or urgent healthcare needs.

A strong and collaborative CCM partnership will facilitate a consistent and predictable cadence for pulling C-CDAs and regularly reviewing updated patient eligibility lists, ensuring accurate and timely enrollment processes.

You and your CCM partner should also collaboratively establish a clear schedule for how frequently your practice will review clinical notifications generated by the CCM team. Effective communication should be bidirectional – in addition to receiving notifications from your CCM partner, your practice should also have the ability to send notifications to the CCM team when you require them to address a specific condition or concern with one of your enrolled patients, ensuring seamless care coordination.

Developing a detailed plan for managing triage calls is another indispensable element of a well-functioning CCM program. Your CCM partner should provide a fully staffed 24/7 care line equipped with a clearly defined and rigorously followed triage protocol. In the event of a patient emergency, the CCM nurses should be trained to immediately contact 911 and initiate emergency medical services. Following any emergency situation, your CCM partner should promptly notify your practice about the event and the patient’s status. Establishing a clear protocol for how your practice prefers to receive urgent notifications is essential so your providers can quickly follow up with the patient and ensure continuity of care.

9. Set Measurable Success Goals and Key Performance Indicators (KPIs)

To ensure the long-term success and continuous improvement of your CCM program, it’s essential for practices to establish practical and measurable goals and track key performance indicators (KPIs). These goals should encompass various critical aspects of the program, including patient enrollment rates, patient retention and satisfaction levels, and the achievement of defined patient care plan goals. You may also set specific goals related to improving your practice’s overall quality scores, such as your performance scores under CMS’s Merit-based Incentive Payment System (MIPS) or under the publicly reported Overall Hospital Star Rating.

Your team should collaboratively define clear and achievable success metrics before commencing CCM implementation. Regularly assess your progress against these goals, and be prepared to proactively evaluate and implement any necessary adjustments to your program strategies to optimize performance and outcomes.

If you are partnering with a CCM provider, they can offer valuable guidance in developing realistic, industry-informed goals and benchmarks based on their experience and data insights. For example, ChartSpan targets a 45% patient enrollment rate as a key performance indicator. To achieve this objective, we implement a strategic phased enrollment ramp-up over the initial six months of the partnership and continuously test and refine new enrollment and patient education methodologies to maximize effectiveness.

The ChartSpan clinical team also establishes internal goals for patient care quality. These include ensuring that every enrolled patient has collaboratively defined care goals documented within the first two months of program enrollment and that every patient receives comprehensive clinical and medication adherence assessments during their initial program interactions. We proactively consult with our partner practices throughout the duration of the partnership to determine any additional specific goals they would like to prioritize and work towards, ensuring alignment with their unique practice objectives.

Learn more about quality improvement in healthcare: Quality Improvement: Processes & Best Practices in Healthcare

10. Maximize Your CCM Program’s Success by Partnering with ChartSpan

CCM program implementation and management can be inherently complex and time-intensive, often causing significant workflow disruptions for healthcare practices. Many practices find that independently implementing a CCM program places substantial demands on their existing staff, necessitates additional infrastructure investments, and generates a significant increase in administrative tasks. However, by strategically partnering with a specialized CCM company, many of these operational burdens are effectively removed, allowing your practice to focus on delivering exceptional care to your chronically ill patients while simultaneously receiving consistent and recurring financial reimbursements for valuable CCM services.

ChartSpan provides your practice with a comprehensive suite of services and resources designed to ensure your CCM program operates seamlessly and efficiently. We have dedicated specialists who expertly manage patient eligibility verification, conduct proactive patient outreach, and effectively enroll eligible patients in the program with your practice’s approval. Our compassionate and highly trained care managers act as a seamless extension of your practice, providing every enrolled patient with personalized monthly check-in calls and the essential assistance and care coordination needed to optimize their individual healthcare journeys. Our 24/7/365 care line is staffed by skilled care coordinators and registered nurses who are readily available to address patient inquiries, provide support, and appropriately escalate emergencies when necessary, ensuring patient safety and peace of mind. Through our proprietary RapidBill technology, we have radically simplified the CCM billing process for your practice, minimizing administrative overhead and maximizing revenue capture.

Furthermore, we provide complimentary quality improvement specialists who will collaborate with your practice to boost your quality performance scores and achieve your quality improvement goals. Our dedicated onboarding team manages the entire staff onboarding process and provides ongoing education and training about the CCM program, ensuring your team is fully equipped for success.

ChartSpan’s 6-Step Framework for CCM Program Success:

Onboard: We provide comprehensive training to your entire staff, ensuring a thorough understanding of the intricacies of CCM program operations and best practices.
Identify & Enroll: We proactively identify eligible patients within your practice, provide you with regularly updated eligibility lists for review, and efficiently manage patient enrollment into the CCM program upon your approval.
Engage: We actively engage with your enrolled patients, building rapport and fostering proactive participation in their individual care management journeys through consistent communication and personalized support.
Intervene: We proactively intervene to help your patients achieve positive clinical outcomes through effective care coordination, proactive preventive care facilitation, and addressing any identified barriers to care.
Measure: We meticulously track key quality measures and performance metrics, continuously monitor program performance, and provide ongoing assistance with program compliance, ensuring adherence to CMS guidelines.
Bill: Our proprietary RapidBill technology streamlines and simplifies the complex billing process, allowing your practice to efficiently review and submit accurate claims to CMS each month, maximizing revenue generation.

Explore How ChartSpan Can Facilitate Your CCM Program Launch

Launching a CCM program independently can present significant challenges. However, it doesn’t have to be an arduous undertaking. When your practice partners with a full-service CCM provider like ChartSpan, you can unlock the transformative benefits of CCM without the operational stress of over burdening your current staff or diverting valuable resources. Contact us today to learn more about the profound impact ChartSpan’s comprehensive CCM program can have on enhancing your practice’s care delivery, improving patient outcomes, and generating sustainable revenue.

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