Eight Questions Asked When Starting A CCM Program


If you are considering a Chronic Care Management (CCM) program for your patients, you probably have some questions! Here are some of the most popular questions we’re asked when starting a CCM program.

1. Can enrollment be done under general supervision for Chronic Care Management?

Many healthcare organizations are unsure if Chronic Care Management can be done under general supervision or not. Ultimately, the answer is yes, CCM can be performed under general supervision, although the circumstances vary slightly. CCM can be performed under general supervision if the patient has been seen within the past twelve months by the NPI you will be billing under for CCM. However, if the patient has not been seen, an initiating visit is required before you can enroll that patient under general supervision.

2. Who is best suited to handle the enrollment of eligible Chronic Care Management patients?

Generally, the healthcare provider is surprisingly not best suited to handle the enrollment process for CCM. In order to enroll a patient in a CCM program, you must get his or her consent. Getting consent requires knowledge of the patient’s deductible, copay, financial, and demographic information – all things that a provider does not typically have readily available. Providers are meant to practice medicine, and not spend their time enrolling patients into a Medicare program. The best type of person to enroll your patients in a CCM program is a trained enrollment specialist who has access to all of that patient information and is trained to be able to respond to common objections.

3. How do you ensure patients engage monthly in a Chronic Care Management program?

Two of the most important things that ensure you successfully engage patients in your Chronic Care Management program are texting and scheduling monthly calls.

Upon enrollment, it’s important to obtain the patient’s consent for compliance purposes and then work with your technology team to set up a robust SMS (texting) system. As more and more patients age into Medicare, the popularity of texting for healthcare purposes is growing significantly. Having an SMS system allows your program a non-invasive way to communicate with your CCM patients, and encourage their engagement in the program.

The other crucial method to ensure your patients engage monthly in your Chronic Care Management is to have patients schedule their monthly call rather than call them at random. When you give patients the ability to schedule their monthly call at the time and date that works best for them, you can see a 200% or more increase in engagement.

4. What is the operational balance needed to staff inbound versus outbound patient calls for a CCM program?

An outbound clinician in a Chronic Care Management program has a singular focus. Their job is to prepare and make calls to patients each month as the standard CCM encounter. The inbound team, however, needs to be available 24/7, every day of the year. They never know when they will get a call or what the patient concern may be. This role requires immediate, available access to patient records and the ability to think quickly and adapt. The inbound team likely requires a more senior person because of the skillset needed.

5. How can you leverage a CCM program to close care gaps that help improve quality scores?

Leveraging your Chronic Care Management to identify and close care gaps and drive quality scores is one of the most important benefits that does not always get enough credit. Traditionally, you would be lucky to see your patient three to four times a year for an in-person visit. With a successfully run CCM program, you can touch those same patients 12-20 times a year. Make sure that you reconcile the patients that are in any of the numerators of your care gaps, see if they are enrolled in your CCM program, and then focus on those care gaps that need to be closed during your monthly CCM encounter.

6. How do you maximize enrollment levels of a CCM program as patients unenroll or pass away? 

The singular, most important operational metric that tells you the health of a Chronic Care Management program is something that ChartSpan has termed, “Net Patient Churn.” Every day more than 11,000 patients churn into Medicare, and 7,000 churn out. This ratio also exists at the practice and hospital levels. Patients “churn in” to Medicare for several reasons including age and diagnoses. Most, unfortunately, “churn out” due to death. You should use the Net Patient Churn metric to measure the number of patients who come in and out of your program. When you consider eligibility requirements for Chronic Care Management, this ratio becomes even more complex as new patients are constantly going to be joining your organization, leaving for another practice, or simply opting out of the program. That’s exactly why enrollment for CCM is not a one-time event. To maximize enrollment levels, you must consistently search for new eligible patients and measure your Net Patient Churn. Churn is a core part of measuring and managing any Medicare program. Measuring churn is crucial to ensuring the program is growing each month, quarter, and year.

7. Can Specialists have a CCM program for their patients?

Medicare has opened up Chronic Care Management to specialists, including but not limited to Cardiology, Nephrology, and Urology. 

8. What does a typical 12-month patient journey look like for a patient enrolled in a CCM program? 

The 12-month patient journey in a Chronic Care Management program can look very different from patient to patient. There’s ultimately a balance of what the patient wants and the clinical protocols that you want to execute during that 12-month period of time. That being said, at ChartSpan, every call with a patient starts the same way: by building rapport, asking the patient how they are doing, and how they are handling their chronic conditions. Sometimes, that introduction can lead the clinician in an unexpected direction. However, from a clinical perspective, you can be confident that clinicians will follow a structured journey that provides you not only with the extra support your patients need, but also the valuable data your practice craves.

ChartSpan uses Chart-Markers™, a human-driven, care coordination methodology that is designed to identify clinical markers that impact patient health. Chart-Markers™ are elements of the program that are designed to identify or address gaps in care and are divided into three categories: Inventory Markers, Identification Markers, and Intervention Markers.

  • Inventory – includes standardized screenings and assessments in the patient’s journey
  • Identify – includes identification of care gaps that your patient may have
  • Intervene – includes action taken to help close identified care gaps

Published: November 14, 2022

Related Articles

Annual Wellness Visit Benefits

Annual Wellness Visits (AWVs) are important for senior Medicare patients and their providers. They provide physicians with crucial information about…

Read More →
The Exponential Savings Potential for Accountable Care Organizations

The Exponential Savings Potential for ACO Participants

The Centers for Medicare & Medicaid Services (CMS) recently released the 2021 performance of the Medicare Shared Savings Program (MSSP).…

Read More →

ChartSpan Announces Partnership with the South Carolina Medical Association

ChartSpan, the leading provider of managed Chronic Care Management (CCM) in the United States, has announced a new partnership with…

Read More →

What Conditions Qualify for Chronic Care Management?

Chronic Care Management is a program that helps patients learn more about their chronic conditions and how they can manage…

Read More →

Effectivity of Chronic Care Management Programs

Thoughtfully designed fee-for-service programs can improve patient outcomes, help drive savings for ACO programs, and save taxpayers money. Medicare’s Chronic…

Read More →

The Chronic Care Model

Research estimates more than four in 10 adults in the US have two or more chronic conditions, such as diabetes, arthritis…

Read More →

ChartSpan Announces Partnership with Health Resource Services

ChartSpan, the leading provider of managed Chronic Care Management (CCM) in the United States, has announced a new partnership with…

Read More →

How to Maximize Medicare Shared Savings

What was your shared savings revenue last year? What was your average attributed beneficiary reimbursement last year? If you could…

Read More →

Like this article?

Subscribe for more.

"*" indicates required fields

First Name*
Last Name*
This field is for validation purposes and should be left unchanged.