Patient and clinician reviewing chart together

How Would You Describe Chronic Care Management to Patients?

Chronic care management (CCM) is essential for patients with two or more chronic conditions. With two-thirds of the U.S.’s population aged 65 and older meeting this criteria, the need for this type of service is widespread. Like with any new medication, treatment, or medical plan, though, your patients may have questions about CCM. Answering these questions in understandable terms will bring them some comfort when first starting CCM.

How Do You Introduce Chronic Care Management to Patients?

When you first introduce the idea of participating in a chronic care management program to patients, you should describe it in the same way that you would a new health condition or medical treatment. You’ll want to provide as much information about CCM as possible to give them a better understanding of what it is, why it’s important, and what they can expect. Having this information upfront will go a long way in persuading patients to participate in a chronic care management plan. Be open and responsive to patient questions, and answer those questions on terms that patients can understand. Make sure to also gather consent from patients about participating in the program once they understand it.

Below, we provide you with some answers you can give to patients should they ask one of these common questions.

What Is Chronic Care Management?

The most common chronic care management definition is ongoing patient care that individuals receive outside their normal primary care physician appointments. Usually, people who receive this type of care have two or more chronic illnesses—or long-lasting conditions expected to get worse over time—that they’re expected to have for 12 months or more. It aims to improve a person's quality of life by helping them better manage the conditions associated with their illnesses. A care manager will reach out to a patient at least once a month. It typically takes place over phone or online rather than in person.

To create and implement the most effective care plans possible, care coordinators will look at external factors, such as transportation issues, as well as a patient’s electronic health record (EHR). They will help patients adhere to treatment plans and recommended lifestyle changes, improve communication between the patient and the medical team, and get access to medical care.

Common conditions that qualify patients for chronic care management include:

  • Alzheimer’s
  • Cancer
  • Diabetes
  • Arthritis
  • Cardiovascular disease
  • Hypertension
  • Stroke
  • Depression
  • Chronic obstructive pulmonary disease (COPD)

How Does Chronic Care Management Help Patients?

After learning about the importance of patient care management, patients may find it can affect them in several ways. For example, CCM programs:

  1. Provide easier access to care, especially for those who have trouble with transportation or who live in an area that’s more than an hour away from the nearest hospital. This point is even more important, too, as the U.S. faces an ever-growing shortage of doctors. For example, one federally qualified health center in West Virginia faced a staffing shortage, which forced their staff to work longer hours. When they started offering virtual appointments, patients and staff alike could make their appointment times without worrying about other tasks, like finding childcare or transportation. Fewer patients canceled appointments because they had the option of a virtual appointment.
  2. Lead to improved health for patients. With CCM, any new health conditions or complications can be caught early, so patients can get the care they need sooner. Improved health also results in patients returning to the hospital less often.
  3. Use technology that makes giving and receiving care efficient and effective. The EHR makes it easier for providers to share information on a patient, which can also make patients feel they’re receiving a more personal experience in their care. A CCM software platform like TimeDoc Health further boosts efficiency by seamlessly integrating with the EHR.
  4. Improve communication between patients and their healthcare providers. When patients notice something about changes in their health, CCM technology gives them a means to easily voice that concern to their care team. And with 24/7 communication access, patients can notify their healthcare providers as soon as they notice these changes. Care coordinators like those who work for TimeDoc Health can also assist patients in getting what they need in care, such as scheduling appointments or helping them find lower cost medications.

This list only scratches the surface on the benefits of CCM, but it can certainly give patients a good sense that CCM will assist them in maintaining and even improving their health.

What Are Examples of Care Management?

You might have some patients who ask what they can expect from CCM. Providing some management of care examples can help them understand what kind of help they may receive. Here are a few you might consider sharing:

Dolores has diabetes and hypertension (high blood pressure). As part of her health plan, her doctor recommended that she eats differently and exercises at least 150 minutes a week. The doctor wants Dolores to track what she eats, what kinds of exercise she does, and how long she exercises each day. Through CCM services, a care coordinator calls Dolores once a month to check in on how well she’s maintaining her nutrition and exercise plan.

Bradford has cancer and clinical depression. He takes medication to treat his clinical depression. Recently, his health insurance changed, and his insurance no longer covers his prescription. They want him to switch to a different medication instead. Bradford’s care coordinator looks for ways that Bradford can save money while remaining on his current prescription. Notes that the care coordinator leaves in the EHR can also notify Bradford’s care team to write a letter to the insurance provider stating that he needs his previous medication.

Having the right CCM platform and services will ensure that your patients with chronic conditions get the care they need, even when they don’t have a scheduled appointment with you. TimeDoc Health is the solution.

Provide Continuous Care to Your Patients With TimeDoc Health

As a healthcare professional, you know that it can be difficult to give all your patients the care they need all the time. A care coordinator and platform like TimeDoc Health makes it much easier on you and the rest of your healthcare team. Our platform integrates with the EHR so that you can see any updates about a patient’s health without too much disruption. It also offers automated reports that calculate charges associated with CCM care so that you can save time on billing.


When you work with TimeDoc Health, you will receive a tailored chronic care management program to fit with your current workflows and processes. To learn more about what our services and platform look like, schedule a demo.