As Medicare continues to emphasize person-centered care, care coordination programs that offer patients consistent, ongoing support are becoming more popular. Chronic Care Management (CCM) is one of the longest-running and most successful of these programs.
Chronic Care Management offers Medicare patients with multiple chronic conditions a care coordinator, care plans, educational resources, and monthly communication. Through these strategies, CCM reduces hospitalizations and Emergency Department visits and builds strong connections between patients and their providers.
In this article, we’ll break down what CCM is and how it can have a positive impact on patients, practices and health systems across Virginia. And if you would like to learn more about CCM, VHHA Solutions can connect you with our new partner, ChartSpan.
What Is Chronic Care Management (CCM)?
Chronic Care Management is a preventative, value-based care program created by the Centers for Medicare & Medicaid Services in 2015. The program strives to improve health outcomes and reduce costs for Medicare patients by offering care coordination to patients with multiple chronic conditions.
To enroll in CCM, a Medicare patient must have:
- 2+ chronic conditions
- A provider visit in the last 12 months
CCM offers the patient:
- A 24/7 nurse line
- 20 minutes of care from a dedicated care coordinator every month
- A personalized care plan and goals
- Assistance with medication refills or appointment scheduling
- Help with Social Determinants of Health Resources
These offerings are designed to help patients manage their health proactively, so they have an active role in their own care and can potentially reduce the time they spend in the hospital or ED.
Why Your Hospital or Practice Should Implement CCM
Once you understand what CCM has to offer, you’re ready to determine whether a CCM program is a good fit for your practice or hospital. Here are a few reasons you may want to implement a CCM program:
1) You can provide additional preventative care to patients.
Chronic Care Management’s primary focus is offering patients coordinated, preventative care every month. The patient’s care coordinator can follow up on their care goals, perform screenings, help the patient set up needed appointments or refill medications, and provide educational resources to help the patient manage their chronic conditions.
Care coordinators can also address Social Determinants of Health needs that might have a dramatic impact on a patient’s health. If a patient expresses that they need help with finding healthy food, safe housing, clothing and toiletries, or transportation, the care coordinator can connect them with local resources.
Overall, CCM can raise patients’ rates of breast and colon cancer screening, diabetic eye exams, and well-controlled blood pressure and A1C levels. One Federally Qualified Health Center that implemented a CCM program saw their rate of patients who received diabetic eye exams go from 48% to 63% when they implemented CCM.
By offering patients monthly preventative care, CCM can improve patient health outcomes and reduce ED visits and hospital readmissions. And since care coordinators work closely with patients’ providers on care plans, goals, and resources, the patient will feel a strong sense of connection to the provider and their practice.
2) You can earn multiple streams of revenue.*
In addition to providing preventative care to patients, CCM can help hospitals, health systems, Rural Health Clinics (RHCs), and Federally Qualified Health Centers (FQHCs) earn recurring, monthly revenue. Medicare reimburses for CCM for each enrolled patient each month, and this fee-for-service model can be a crucial source of revenue, especially for struggling hospitals and health systems.
In 2024, CCM will be reimbursed at $60.63 per patient, per month in Virginia. RHCs will receive $73 per patient, per month, and FQHCs will also receive higher compensation, though theirs will vary by geographic adjustment factor.
Furthermore, CCM plays a crucial role in value-based care models. By improving patient outcomes and reducing overall healthcare costs, providers participating in Accountable Care Organizations (ACOs) or similar arrangements can earn performance-based bonuses tied to quality metrics. This creates a win-win situation, where better patient care translates to both financial impact and improved population health.
*Results may vary by provider.
Changes to CCM for 2024
2024 will bring a few changes to Chronic Care Management. One is that the Medicare Physician Fee Schedule conversion factor has universally decreased by 3.4%. Hospitals or health systems that don’t have CCM or other preventative care offerings could employ these programs to offset the decrease in their Medicare reimbursements.
Secondly, the Physician Fee Schedule for 2024 clarifies that practices can obtain consent for CCM in multiple ways (such as over the phone or in person) and that direct supervision by a provider is not needed for consent.
CCM consent has always been permitted to take place under general supervision. But by explicitly stating this, CMS makes it clear that health systems can partner with Chronic Care Management providers throughout the lifecycle of their CCM program, including during enrollment.
CCM is likely to continue changing year over year, but an experienced CCM provider can help your practice or health system navigate the program and continue offering preventative care to patients.
Exploring a CCM Program in the Future
If you’d like more details about what Chronic Care Management will look like in 2024, VHHA Solutions and ChartSpan hosted a webinar called, “Mastering Chronic Care Management in a Changing Landscape” to discuss CCM, its benefits, and its ongoing changes. You can access the recording of that webinar here.
And if you’d like to learn more about CCM immediately, you can visit ChartSpan’s website to view details about Chronic Care Management.
