What Is Chronic Care Management?
Chronic Care Management is a Medicare-supported program designed to help patients manage two or more chronic conditions that are expected to last at least 12 months (or until the end of life) and that place the patient at significant risk of decline or complications.
Examples of chronic conditions include:
- Diabetes
- Hypertension
- Heart disease
- COPD
- Arthritis
- Depression
- Chronic kidney disease
Chronic Care Management helps ensure patients receive consistent support between office visits, improving outcomes, enhancing communication, and reducing unnecessary hospitalizations.
What CCM Includes:
Each month, eligible patients receive:
Ongoing monitoring of health status
At least 20 minutes of non-face-to-face care coordination
Medication management and review
Coordination with specialists and other providers
24/7 access to care team support for urgent needs
Who is Eligible:
Patients may qualify if they:
Require ongoing care coordination
Have two or more chronic conditions
Have conditions expected to last at least 12 months