Doctor taking notes

What Does a CCM Care Plan Look Like?

A CCM (chronic care management) care plan is an evolving document that addresses all the health needs of a patient living with multiple chronic medical conditions. One of the important tasks of any chronic care management program is to enable healthcare providers, care coordinators, and patients to work together to create, implement, and update this plan.

This article will cover:

  • The definition of a care plan, and what governing bodies oversee its use
  • What a care plan should include
  • Who is authorized to write and use this care plan

What Is a Chronic Care Management Care Plan?

A CCM care plan is a personalized plan for addressing the medical and general wellbeing needs of a patient with multiple chronic health conditions. To better illustrate an effective CCM care plan and why it may be needed, let’s look at a hypothetical 70 year-old patient named Linda with kidney disease, arthritis, and diabetes.

To meet CCM care plan requirements, Linda’s plan should include her conditions, providers, upcoming appointments, medications, any concerns of hers or her doctors’, and a way of monitoring progress on any recommended lifestyle changes.


Condition: Kidney disease that resulted in kidney transplant 10 years ago

Primary Provider: Nephrologist, Dr. A

Last Appointment: 01/02/2023

Medications: Anti-rejection medication

Recommendations: Monitor kidney function quarterly


Condition: Arthritis, significantly impacting use of both hands

Primary Provider: Rheumatologist, Dr. B

Last Appointment: 03/04/2023

Medications: Anti-inflammatory medication

Recommendations: Exercise to strengthen muscles around joints, weekly physical therapy sessions to improve flexibility and strength


Condition: Diabetes, Type 2, newly diagnosed

Primary Provider: Endocrinologist, Dr. C

Last Appointment: 05/06/2023

Medications: Insulin pump

Recommendations: Monitor blood sugar levels and follow dietary recommendations for controlling blood sugar

When a care manager contacts Linda monthly, they will talk through the care plan, addressing Linda’s ongoing medical concerns and questions about following the recommendations. Linda might have the most questions about the dietary recommendations for her newly diagnosed diabetes, and a care coordinator would be able to provide resources for understanding and enacting the needed changes.

With all a patient’s health information in one place, it becomes much easier to see the whole picture of someone’s health. A patient or care coordinator can quickly see if it’s time to schedule a followup appointment with any providers, double-check all medications, and build recommended lifestyle changes into daily habits.

A CCM platform, like TimeDoc, will offer templates created by physicians that make creating individual care plans for patients a breeze. They are even built to integrate with your Electronic Health Record (EHR) system to simplify record keeping and documentation.

What Are the 5 Main Components of a Care Plan?

Although there isn’t an exact template that must be followed for a CCM care plan, there are several important elements that need to be included and some specific ways in which this care plan needs to be used. Let’s look at both sets of requirements, provided by the Centers for Medicare and Medicaid Services (CMS).

An effective care plan…

  1. Centers around the needs of the patients, including functional, cognitive, mental, physical, psychosocial, and environmental requirements. 
  2. Includes a resource list for places a patient can access support for these needs.
  3. Is comprehensive, including all health conditions with a focus on chronic issues.
  4. Exists as an electronic document, with copies provided to caregivers and patients.
  5. Is shared with billing agencies and the patient’s healthcare providers.

A care plan should include:

  • A comprehensive list of health conditions
  • The expected prognosis and outcomes of these conditions
  • Treatment goals that are measurable, with a place to record progress
  • An assessment of functional and cognitive abilities of the patient
  • A strategy for managing chronic symptoms
  • Any interventions planned, along with an expected timeline
  • A complete medication list
  • An evaluation of the patient’s environment, to determine if it supports their health goals
  • An evaluation of their caregivers, to determine if additional support may be needed 
  • Any external resources being used by the patient, like community support groups
  • Regularly scheduled reviews of the plan, allowing it to be revised as needed

Who Can Write a Care Plan for Chronic Care Management?

CCM care plans should be written collaboratively between the patient and clinical staff being overseen by the physician of the patient. This clinical staff might include a chronic care management nurse, holding a license like LPN, RN, or NP. It could also include other licensed clinical staff like an MA, PA, or LCSW.

Once a care plan has been written, monthly check-in calls using the plan can be done by any of the above mentioned or a trained care coordinator using a chronic care management call script. This coordinator can be internal staff from the hospital or medical center, or provided by a third party service. TimeDoc offers assistance in both training internal staff or staff augmentation for whichever options fits best.

TimeDoc: Chronic Care Management Support that Works 

At TimeDoc Health, we know that providing the best care to patients is a medical facility’s top priority. That’s why we make it easy to plan, carry out, and document CCM, all in one easy-to-use, scalable platform. We integrate seamlessly into patients’ electronic medical records and offer care coordinators to streamline your CCM program, so your staff can spend their time doing what matters most…caring for people. Contact us now or book a demo to see how we can help you.