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Chronic Care Management

FACT: Chronic Care Management (CCM) has a profound positive impact on controlling patients' multiple chronic conditions, including major lifestyle diseases such as hypertension, diabetes, and heart disease.


By providing continuous, coordinated care, CCM helps patients manage their conditions more effectively, leading to better health outcomes. Patients benefit from regular monitoring and personalized care plans, which ensure timely interventions and adjustments to treatment as needed. This proactive approach reduces the risk of complications and hospitalizations, ultimately enhancing the quality of life. Additionally, CCM promotes patient education and self-management, empowering individuals to take an active role in their health. By addressing lifestyle factors and providing support for healthy behaviors, CCM helps control blood pressure, regulate blood sugar levels, and improve cardiovascular health, thereby mitigating the progression of these chronic diseases. Overall, Chronic Care Management fosters a comprehensive and sustained approach to managing multiple chronic conditions, leading to improved patient health and reduced healthcare costs.


Chronic care management includes a comprehensive care plan that lists serious health problems and goals, other providers, medications, community services needed, and other information about the health of the patient. It also explains the care a patient needs and how the care will be coordinated.  The health care provider will provide an agreement to the patient to provide chronic care management.

Then, the provider prepares the care plan, helps with medication management, provides 24/7 access for urgent care needs, provides support when the patient goes from one health care setting to another, reviews medications and how the patient takes them, and helps with other chronic care needs.

For 2 or more serious chronic conditions (like arthritis and diabetes) that are expected to last at least a year, Medicare may pay for a health care provider’s help to manage those conditions.

Reimbursement Reviews

Research conducted by a highly successful Remote Patient Monitoring (RPM) software company has demonstrated significant benefits for healthcare providers implementing these technologies. Key findings include:

  • 29% Reduction in Hospitalizations**: Providers reported a substantial decrease in hospital admissions, improving patient outcomes and reducing costs.

  • 87% Patient Retention at One Year**: High patient retention rates indicate strong patient engagement and satisfaction with care.

  • Average Net-New Revenue Exceeding $6,800 per Provider per Month**: Providers experienced notable financial benefits, adding significant revenue through effective management and monitoring.

  • 91% Patient Satisfaction**: High levels of patient satisfaction reflect the quality and effectiveness of care provided.


These outcomes suggest that healthcare providers can achieve clinical, financial, and operational success through the adoption of:

  • Chronic Care Management**: Ongoing management of chronic conditions to improve patient health and reduce complications.

  • Principal Care Management**: Focused care for patients with one high-risk condition.

  • Transitional Care Management**: Ensuring smooth transitions from hospital to home to prevent readmissions.

  • Remote Patient Monitoring**: Continuous monitoring of patients' health status to catch issues early and intervene promptly.

  • Behavioral Health Integration**: Incorporating mental health services into primary care to provide comprehensive care.


By implementing these management and monitoring services, healthcare providers can enhance patient outcomes, increase satisfaction, and achieve financial growth.

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