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Care Management Benefits: Benefits of Chronic Care Management and Advanced Primary Care Management

Care management programs, especially comprehensive care management programs, offer patients personalized, ongoing care that helps them take charge of their health. In turn, practices are given benefits like engaging their patients, improving their quality scores, and generating reimbursements for their practice.

Comprehensive care management programs, like Advanced Primary Care Management (APCM) and Chronic Care Management (CCM), offer ongoing care to the patient for as long as they’re enrolled in the program. This differentiates them from other care management programs, like Transitional Care Management, that apply only for a specific time period, such as when the patient has just left the hospital.

Because APCM and CCM focus on ongoing care, they are empowered to produce greater benefits for patients, who receive a care manager, care plans, and 24/7 access to care. By understanding the benefits of APCM and CCM and how they differ, you can determine which care management program offers the greatest incentives for your practice and your patients. 

Care Management Benefits for Patients

Offering Medicare patients an exceptional experience and improving their health outcomes is a priority for many practices and health systems. Regular, personalized care can help you achieve those goals. 

Both Advanced Primary Care Management and Chronic Care Management offer regular check-ins with a dedicated care manager, 24/7 access to care, opportunities to address gaps in care, and community resources. However, CCM allows for primary care and some specialty practices offer ongoing care to their patients with chronic conditions, while APCM focuses solely on primary care providers with expanded quality and discharge management requirements. 

Ongoing Care Between Appointments 

APCM and CCM both offer patients a care manager to check in with them between appointments and help them build a customized care plan with care goals. A patient may agree to steps to manage their chronic conditions at an appointment, but then return home without a clear idea of how to achieve those goals.

Care managers can counteract this by helping patients choose SMART (Specific, Measureable, Achievable, Realistic, and Time-based) goals to improve their health. For example, a patient with hypertension who rarely exercises may have a goal to begin walking for 20 minutes per day, 5 days per week. 

Their care manager can help them set their initial goal and follow up with the patient after one or two months to see if they’ve achieved it and are ready to set a new goal. Their care manager can offer encouragement, help them find safe places in their area to exercise, and be a source of accountability for the patient on an ongoing basis.

In addition to setting care goals, care managers maintain a comprehensive care plan that includes a patient’s diagnoses, their interactions with their care managers, medications, visits to other providers, planned interventions, and other health information. Under APCM and CCM, the patient has access to this care plan so they can collaborate with the care manager on protecting their health. 

24/7 Access to Care

Chronic Care Management and Advanced Primary Care Management each offer 24/7 access to care, so patients can reach out for assistance in between their proactive care manager meetings. Smaller practices often don’t have the resources to provide care at night, on weekends or during holidays. Even practices and health systems that already offer 24/7 care don’t always have comprehensive care plans at hand for patients who call in. 

When a patient calls the 24/7 care line as part of a CCM or APCM program, the care manager can pull up the patient’s care plan to understand their conditions. They can then offer resources or direct the patient to a nurse who can perform triage for urgent or emergent symptoms.

An effective care management program will use Schmitt-Thompson or similarly verified triage protocols to ensure patients are directed to the right source of care, whether that’s their regular provider, urgent care, or the ER. Having 24/7 triage available can help prevent unnecessary ER visits, while still ensuring patients receive needed emergency or urgent care. 

Gaps in Care

Because care managers interact with patients so often, they have recurring opportunities to address gaps in care. In addition to checking on care goals, care managers can perform gap in care assessments and direct patients back to their provider for vaccinations, screenings, or exams. Care managers can also check on and record patients’ blood pressure or A1C readings to ensure their chronic conditions are well managed.

By sharing this information with the patient’s practice, care managers can help providers improve their quality scores, whether they participate in MIPS, MVPs, ACOs, or another Advanced Alternative Payment Model. Addressing gaps in care can also help patients protect their long-term health by ensuring they receive the preventive care they need. 

Social Determinants of Health and Community Resources

Safe housing, nutritious food, reliable transportation, and other Social Determinants of Health can have a tremendous impact on patients’ health. But patients’ socioeconomic situations can change quickly, especially as food and housing continue to become more expensive.

Care managers can perform Social Determinant of Health screenings on a regular basis or when a patient expresses a need. They can then direct the patient to housing agencies, food pantries or delivery services, transportation organizations, and community centers in their neighborhood. This helps practices ensure a lack of basic needs doesn’t stand in the way of their patients’ health and well-being.

Exclusive Benefits of Chronic Care Management

Chronic Care Management and Advanced Primary Care Management offer many overlapping benefits for patients. However, Advanced Primary Care Management is designed for providers who serve as the primary source of care for the patient. This means it isn’t available to many specialists, who wish to leave those responsibilities to the patient’s primary care provider.

Supporting Specialty Care

Chronic Care Management does not require the provider to serve as the primary point of care and is available to any Medicare patients who have two or more chronic conditions. Since many of these patients visit a specialist to treat their chronic conditions, CCM empowers specialists to offer care management.

CCM care managers can focus on chronic conditions relevant to the provider’s specialty or on conditions that have secondary effects on the specialty. For example, a care manager could help an ophthalmology patient care for their cataracts while also helping them manage their high blood pressure or diabetes to prevent further damage to their eyes.

CCM also helps specialists receive information about the patient’s encounters with their primary care provider. The patient’s visit information with their PCP can be stored in their care plan. If the patient raises health concerns during check-ins, care managers can connect the patient to their PCP or to their specialist, depending on their needs. 

Exclusive Benefits of Advanced Primary Care Management

Advanced Primary Care Management differs from Chronic Care Management in that it doesn’t require patients to have any chronic conditions—it is open to all Medicare beneficiaries. This open availability makes the program appealing to many primary care providers. 

APCM also offers other benefits for primary care patients, like discharge management to support them when they leave the hospital, two-way digital communications, and population analytics to identify specific gaps in care and determine which interventions patients most need. By examining these benefits, providers can determine whether APCM or CCM is a better fit for their practice. 

Support When Patients Leave the Hospital

Immediately after they leave an inpatient setting, patients are especially vulnerable to sudden health declines or hospital readmission within the next few months. It’s difficult for many patients to transition from 24/7 care to managing their health and a new care plan on their own.

APCM addresses this gap by providing support for patients when they leave the hospital. Within 48 hours of a patient being discharged from an inpatient setting, their APCM care manager must reach out to help them review their care plan and ensure they have access to any new medications or durable medical equipment. 

Their care manager should also help them schedule a follow-up appointment with their provider and find transportation to reach that appointment if needed. While CCM can include support after discharges, it’s not a strict requirement and often relies on the patient sharing that they’ve been discharged. APCM requires the practice or the APCM provider to actively look for discharges so they can proactively reach out with support. 

Two-way Digital Communications

APCM and CCM both require that practices give patients multiple ways to communicate with them, including a 24/7 phone line, and options like two-way texting or a patient portal. However, APCM goes further by requiring two-way, digital communications and communications that allow patients to send images for remote evaluation. 

Practices can achieve these aims through email, text, telehealth calls, or digital surveys. A reliable APCM provider can help set up methods of communication the practice doesn’t already have, giving patients the freedom to choose communications that work for them.

Population Analytics to Identify and Address Gaps in Care

While Chronic Care Management can address gaps in care and help practices improve their quality measures, APCM makes population analytics a critical element of care management instead of an optional one. Practices must proactively identify gaps in care for their APCM-enrolled patients and come up with a plan to have care managers reach out to patients and provide interventions. 

While every practice has records of the care patients have received at their practice, many don’t have accurate records from other practices and pharmacies where patients may have received treatments. To run APCM, practices will either need to have software or partner with a vendor to obtain accurate information from nationwide databases. This information will empower quality teams to identify what care patients have received and which care gaps care managers need to address. Care managers can perform digital or phone assessments and refer patients back to their provider for screenings, exams, and vaccinations, leading to better quality performance and better health outcomes for patients. 

Care Management Benefits for Providers

While many practices place improving the patient experience first, care management also brings benefits for providers and practices. Ongoing, proactive care programs can lead to improved patient outcomes, increased revenue, and higher quality measures for practices that deploy them. 

Improve Patient Outcomes 

Medicare claims data for ChartSpan’s CCM program demonstrates that care management programs have the ability to reduce total cost of care, inpatient costs, and ED costs. These reductions in costs allow practices to demonstrate cost savings for their quality programs, but also demonstrate that patients have fewer inpatient and ED claims, indicating their health conditions are less likely to escalate.

Patients enrolled in care management saw a 21% reduction in overall Medicare costs, vs. patients who were eligible for care management and didn’t enroll. Costs of ED visits decreased by 19%, and costs of inpatient visits decreased 36%. Care management also proved effective at preventing hospital readmissions, with patient readmissions decreasing by 52% within the first 30 days and dropping to 0% in the 60-90 day range. Preventing avoidable hospitalizations improves patients’ overall health and quality of life. 

Increased Revenue from Reimbursements and Shared Savings

Advanced Primary Care Management and Chronic Care Management combine FFS revenue and improved performance in shared savings programs to generate revenue for practices. With sources of federal funding constantly shifting, having multiple, reliable sources of revenue enables practices to keep their doors open for the patients counting on them. 

For CCM, practices receive FFS revenue per month, per enrolled patient when they provide 20 minutes of care. For APCM, practices receive FFS revenue per month, per enrolled patient when they offer all the services required by the practice model.

Additionally, CCM or APCM can improve quality performance in MIPS (CCM), MIPS Value Pathways (CCM and APCM), ACOs (CCM and APCM), and Advanced Alternative Payment Models (APCM). By improving your performance for these programs, you can increase your shared savings revenue.*

*Results may vary by provider. 

Enhanced Performance on Quality Measures

APCM requires improving quality performance. The program states that practices must participate in the Value in Primary Care MVP, an ACO, or an Advanced Alternative Payment Model. Through population health analytics and focusing on gaps in care, you can improve your performance for any of these programs, ensuring your patients have preventive care and you have high quality scores.

While CCM does not explicitly have quality as one of its requirements, the program nonetheless offers multiple opportunities to address gaps in care like cancer screenings, adult vaccinations, and A1C or blood pressure levels. By addressing these gaps in care, CCM also supports you in improving your MIPS, MVP, or ACO quality performance. 

Discover the Benefits of Care Management

Care management empowers you to improve patient experience through a personalized care manager, clear care goals, support with community resources, and a 24/7 care line for unexpected needs. Launching a care management program can also help you generate reliable revenue for your practice and improve your quality performance, all while enhancing your patients’ long-term health outcomes.

If you’d like to learn more about the differences between APCM and CCM and how each program can benefit your practice, check out our free, comprehensive guide on Advanced Primary Care Management vs. Chronic Care Management.