4 Steps for Implementing a Successful Chronic Care Management (CCM) Program in 2024

A Chronic Care Management (CCM) program enhances care for patients with chronic conditions while streamlining practice management. Let's explore the steps to launch a successful CCM program, focusing on eligibility, technology, and billing intricacies.

1. Understand CCM services

• Familiarize yourself with the CMS service requirements.
• Key services (outside of face-to-face patient visits) include:
  • Management of chronic conditions
  • Management of referrals to other providers
  • Management of prescriptions
  • Ongoing review of patient status
• Who can provide and bill for CCM services?
  • Physicians
  • Non-Physician Practitioners (NPPs)
    • Certified Nurse Midwives (CNMs)
    • Clinical Nurse Specialists (CNSs)
    • Nurse Practitioners (NPs)
    • Physician Assistants (PAs)

2. Determine which patients are eligible for CCM services

Patient requirements:

• Two or more chronic conditions expected to last at least 12 months (or until the death of the patient)
• Patient consent (verbal or signed)
• Personalized care plan
• 24/7 patient access to a member of the care team for urgent needs
• Enhanced non-face-to-face communication between patient and care team
• Management of care transitions
• At least 20 minutes of clinical staff time per calendar month spent on non-face-to-face CCM services directed by physician or other qualified health care professional

3. Implement technology for care coordination and patient tracking

Utilizing technology to facilitate care coordination and patient tracking is essential. Whether integrated within Electronic Health Records (EHR) or as a standalone application, platforms enable seamless communication with patients via messaging, voice calls, and more. These platforms offer a streamlined avenue for practitioners to ascertain patient eligibility, manage ongoing communication effectively, and ensure accurate billing with appropriate CCM codes - all within a single interface. By adopting such technologies, practices can significantly enhance the quality of patient care and increase revenue while maintaining the simplicity and efficiency of existing workflows.

4. Understand the CCM billing codes

Quadrant Health is a comprehensive CCM platform that allows practices to personalize and perform patient care plans using generative AI. Learn more here or request a demo here.