Chronic care management (CCM) is an essential component of achieving long-term health and wellness. This approach involves providing ongoing and coordinated care to people with chronic conditions, enabling healthcare providers to deliver better outcomes and enhance the quality of life for their patients.

However, the statistics on chronic diseases underscore the dire need for better CCM. Chronic diseases account for 70% of all annual deaths, as reported by the Centers for Disease Control. These numbers are heart-wrenching, and they demand a robust response.

Yet the U.S. is already bleeding resources trying to manage the growing problem of chronic diseases. In fact, $3.69 trillion of the nation's annual healthcare expenses go toward managing these diseases. However, despite such efforts, the prevalence of chronic diseases in the U.S. continues to grow steadily by seven to eight million people every five years.

This predicament leaves health professionals wondering, ”How do I start a chronic care management program that works? One that’s sustainable and makes a dent in the problem?” Unfortunately, the issue of financial viability is a daunting obstacle on the path to a successful CCM program. Limited resources and time constraints often make it difficult to successfully launch and maintain programs that deliver on their promised benefits.

In response to this challenge, many healthcare facilities are turning to innovative chronic care management solutions that combine the power of a CCM platform with supplemental and flexible care coordination services. By leveraging the latest technology and providing personalized care for each patient, these facilities are making a substantial impact on the problem of chronic disease management.

Whether you're just starting to build a CCM program or looking for ways to enhance your existing efforts, this article is a must-read. We'll guide you through the basics and show you how to leverage a chronic care model within the framework of value-based care (VBC). By embracing the latest technology and innovative care strategies, the health care system can create more compassionate and effective strategies that prioritizes the needs of patients.

What Are the 4 Major Chronic Diseases?

Cardiovascular disease, cancer, chronic respiratory disease, and diabetes diseases are the four major chronic diseases. These diseases are responsible for a significant portion of healthcare spending and are associated with high morbidity and mortality rates. 

CCM can play a crucial role in managing chronic diseases like these. More specifically, here's how a patient suffering from each condition could benefit from CCM:

1. Cardiovascular Disease - CCM can provide patients suffering from cardiovascular disease with customized care and consistent monitoring of critical health indicators, such as blood pressure and cholesterol levels. Additionally, a patient's care coordinator can serve as an accountability partner in adopting healthy lifestyle changes, like exercise and dietary modifications, to reduce the risk of cardiovascular disease.
2. Diabetes - CCM is a powerful ally for patients battling diabetes, offering assistance in managing blood sugar levels and monitoring foot health for nerve damage and poor circulation. By mitigating the risk of complications like kidney disease and vision loss, CCM empowers patients to reclaim command over their well-being.
3. Cancer - With the help of CCM, patients battling cancer can receive comprehensive care coordination between multiple healthcare providers. This includes managing the often difficult side effects of treatment while also offering vital emotional support to patients and their families throughout their battle. A CCM program provides a lifeline to patients, ensuring they receive the personalized care they need to fight cancer with confidence and hope.
4. Chronic Respiratory Disease - Through CCM, patients with chronic respiratory diseases receive regular monitoring of their respiratory symptoms and guidance on managing their medication and oxygen therapy. Furthermore, CCM can educate patients on avoiding triggers that exacerbate respiratory symptoms. As part of this education, patients can learn about lifestyle changes that promote healthy lung function, such as quitting smoking.

The Purpose of Chronic Care Management

According to the National Association of Chronic Disease Directors, over two-thirds of all deaths in the United States are caused by complications related to one or more of five chronic diseases: 

1. Heart disease
2. Cancer
3. Stroke
4. Chronic obstructive pulmonary disease
5. Diabetes

The core purpose of chronic care management (CCM) is to help physicians monitor and treat chronic conditions effectively and ensure that patients are supported when navigating the complex healthcare system. CCM initiatives are designed to consider all complications brought on by chronic conditions, as well as external factors that impact a patient’s health. As patients onboard, care providers assess all possible challenges and develop a unique care plan to ensure all patient needs are met. Sounds pretty straightforward, right?

Unfortunately, it’s not. 

It’s well known that conventional CCM approaches possess significant shortcomings related to the overall care processes. Although it is clear that CCM works in theory, successful execution is much more nuanced. Currently, physicians are held back by many significant challenges, including:

• Limited resources and staff
• Constricted time-frames
• Budget constraints

Each of these hurdles hinder health professionals’ ability to launch and sustain profitable CCM programs that truly deliver. So, how can the healthcare system make CCM work the way it is supposed to? To provide sustainable, flexible, and cost-effective care for chronic conditions, healthcare officials can lean on innovative tech-enabled CCM services for the ongoing treatment of chronic conditions. 

Learn More About How to Describe CCM to Patients →

How to Create a Chronic Care Management Program

Although creating a CCM program is complex, the rewards are immense. There are eight general steps providers can take to get your CCM program up and running:

1. Assess your Facility's Capabilities and Resources 
2. Identify Eligible Patients 
3. Consider Value-Based Care 
4. Develop a Care Plan 
5. Assign Care Coordination Staff 
6. Train and Empower Staff 
7. Implement Technology 
8. Monitor and Evaluate 

Keep in mind that the specific steps for starting a CCM program may vary depending on your practice's needs and resources. Consider seeking guidance from other healthcare organizations or consultants with expertise in chronic care management to help you develop and implement a successful program. 

Related: What is a Chronic Care Model? →

The Duties of Chronic Care Management

CCM services are typically provided by a care team that includes physicians, nurses, and other healthcare professionals. The duties of chronic care management may involve the following:

• Care Coordination - The care team works together to create a comprehensive care plan for each patient, taking into account their medical history, current health status, and individual needs and preferences.
• Regular Follow-Ups - The care team schedules regular check-ins to assess the health status and make any necessary adjustments to the patient’s care plan. 
• Patient Education - During these follow-up calls, the care team educates the patient about their diabetes condition, including symptoms to watch for and strategies for managing the condition.
• Medication Management - The care team helps the patient manage their medications, ensuring they are taking the correct dosage at the appropriate times and monitoring for potential side effects or drug interactions. 
• Remote Monitoring - The advantages of remote monitoring become clearer every day, with recent studies suggesting that remote monitoring leads to lower hospitalization and mortality rates. 

Ultimately, the primary duty of CCM is to ensure that patients with chronic conditions receive the support and guidance they need to achieve their health goals. By taking this patient-centered approach and providing comprehensive care, you can help these individuals manage their conditions effectively and lead healthy, fulfilling lives.

Learn More about CMS Chronic Care Management Guidelines →

TimeDoc Health: Making Every Minute Count in Your Chronic Care Management Workflow

At the heart of every great healthcare organization is a commitment to excellent patient care. With TimeDoc Health’s CCM services and EHR-integrated platform, that commitment is taken to the next level.

We understand that physician and clinical staff time is precious and must be spent with the utmost care and attention to detail. That's why we've designed an easy-to-use interface that seamlessly integrates with your patient charts. This allows providers to document patient activities directly from their charts without interrupting clinical workflows.

What other benefits can you look forward to with TimeDoc Health? 

• Supplemental and flexible care coordination efforts from our team of experienced certified/registered medical assistants, should you need them
• Less time spent on CCM billing with automated reports that instantly calculate charges using documented activities and then post them to your EHR
• Comprehensive training sessions for your entire clinical staff on the TimeDoc platform and additional training as needed
• A physician-created chronic care management template for each chronic disease that guides care coordinators through CCM services for every patient
• Billing support for transitional care management (TCM), behavioral health integration (BHI), and complex CCM codes

At TimeDoc Health, we believe that patient outcomes should always come first. That's why we're committed to delivering not just financial security and predictability, but also unmatched satisfaction to both you and your patients. 

Are you ready to experience the TimeDoc Health difference? Request a demo today and take the first step towards a more efficient, effective, and satisfying healthcare practice.