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 and hypertension. Managing these issues typically calls for preventive care — something a reactive healthcare system struggles to provide. The Chronic Care Model appeared several decades ago to address these shortcomings by providing a framework for delivering care. It encompasses many parts of healthcare delivery, from clinical information systems to resources in the community. Today, providers often use Chronic Care Management (CCM) to reach the goals of the Chronic Care Model.

With the Chronic Care Model explained, you’ll see how valuable a strategy like CCM can be in helping patients and providers enjoy benefits like improved outcomes and cost savings. We’ll explore the Chronic Care Model components, how CCM relates, and what it can do for you and your patients.

What Is the Chronic Care Model?

The Chronic Care Model is a framework designed to help members of the healthcare system deliver effective, high-quality care for people with chronic conditions. The idea that we only need to see a provider during acute illness or injury doesn’t align well with chronic conditions that require a preventive approach with ongoing assessment, treatment and education. The Chronic Care Model provides guidelines for transitioning to the preventive approach so patients can enjoy better health and our society can minimize the extensive costs associated with these conditions.

In this model, patients mostly receive face-to-face assistance from their primary care physician, but the framework covers many different entities and support structures. Everything from your choice of electronic health record (EHR) to a patient’s level of autonomy can affect chronic care success. The Chronic Care Model touches on these different areas for a comprehensive strategy that brings together patients, providers and the system itself.

With evidence-based concepts, the model aims to support providers with necessary resources and knowledge and empower patients to take an active role in their health. It applies to many practice settings, populations and chronic illnesses. Some primary benefits of this approach include a healthier population and cost savings for practices and patients.

For example, one of the principles of Chronic Care Management is self-management, which focuses on helping patients take charge of their health. If a diabetic patient doesn’t have a good grasp of blood sugar fluctuations, they may not understand how their diet affects their condition. Robust education and resources might help them eat better and make significant clinical changes. Successfully managing diabetes could help them reduce hospitalizations or emergency room visits. Minimizing medical requirements then helps the patient save money and reduces the financial burden on the healthcare system as a whole.

By extending this chronic model to the millions of people living with chronic conditions, we can make lasting, valuable changes to population health and financial issues in the industry.

When Was the Chronic Care Model Developed?

The Chronic Care Model started in the late ‘90s as a group effort led by Edward H. Wagner, MD, MPH, director of the MacColl Institute for Healthcare Innovation. Working with the Group Health Cooperative of Puget Sound, he got the ball rolling when he collected information from various sources on chronic care strategies, codifying it into the structured model.

In 1998, the Robert Wood Johnson Foundation funded the testing and development of the model as part of the Improving Chronic Illness Care (ICIC) program. ICIC aimed to create a proactive model for patient-centered and population-based care for chronic illnesses. As the years went on, ICIC continued developing and refining the model, offering clarity, assessment tools and resources.

More recently, the Chronic Care Model got a boost through Chronic Care Management. After CMS introduced CCM, providers could receive reimbursement for these programs delivered to Medicare beneficiaries. It helped mitigate chronic care’s financial challenges and is a valuable part of modern-day value-based care initiatives.

Key Principles of the Chronic Care Model

The six Chronic Care Model elements address different aspects of care delivery for a comprehensive, multifactored approach.

1. Health System

Of course, a health system needs to offer safe, high-quality care. It should have a business plan that reflects a dedication to implementing the Chronic Care Model across the organization. This aim includes:

  • Visible support at all levels of the organization.
  • Effective improvement strategies.
  • Open and systematic problem-solving and error handling.
  • Incentives for improved quality of care.
  • Agreements that facilitate care coordination.

2. Community

Community resources can be a vital part of helping patients access care and receive the support they need. Healthcare organizations can mobilize these resources, such as schools, governments, nonprofits and faith-based organizations, to better help patients. Providers might encourage program participation and awareness or form partnerships with them. Since providers have a unique understanding of patient needs, they can assist organizations in filling gaps and providing needed services, such as transportation and support groups.

Providers can also get involved in industry groups or government and advocate for policies and practices that improve care.

3. Self-Management Support

A major part of person-centered care is patient empowerment, in which patients are encouraged to take an active role in their care with all the information they need to understand their condition. Providers can support them in setting goals, identifying challenges and monitoring their health. They can also stress the importance of the patient’s role in their health and lean on community resources for ongoing support.

4. Delivery Systems

How healthcare is delivered also makes a considerable difference — it must be effective and efficient with support for self-management strategies. Some elements of a delivery system that support chronic care include:

  • Regular, proactive visits addressing patient goals.
  • Team members with defined roles and distributed care tasks.
  • Clinical case management services for complex patient needs.
  • Regular follow-up appointments or communication.
  • Care that patients understand and that aligns with their cultural backgrounds.

5. Decision Support

As with any healthcare setting, decisions must be backed by data and evidence. Practices should stress the importance of continuing education, professional collaboration and patient education, while providers should incorporate evidence-based guidelines into everyday clinical practice. Proven provider education strategies can ensure continuous learning, and the input of both specialists and primary care providers supports informed decision-making.

6. Clinical Information Systems

Leveraging data organization is necessary to facilitate effective, efficient care. Modern technology offers significant benefits to both patients and providers, who can access tools like patient registries, care reminders and information-sharing resources. Providers can support their patients with chronic illnesses by implementing robust clinical information systems. They may identify subpopulations that could benefit from proactive care, develop data-backed patient care plans and monitor practice performance and patient status over time.

Why Is the Chronic Care Model Important?

Chronic conditions are a leading cause of death in the US, and they’re incredibly costly, with about 84% of health care costs going toward treating chronic conditions. The prevalence of these issues is only expected to grow as the number of older adults increases, a population heavily affected by chronic conditions.

With such significant challenges, effective management of chronic conditions is a vital consideration moving forward. People typically only visit the doctor when sick or injured, which is the basis of traditional healthcare reimbursement. Fee-for-service means providers get paid based on how often their patients come in to see them. The Chronic Care Model has contributed to the shift to value-based care, in which providers are pushed to offer preventive care and help improve population health overall.

The model is especially useful in primary care, where providers play a pivotal role in streamlining healthcare practices and improving patient outcomes.

Is the Chronic Care Model Effective?

Researchers have found the Chronic Care Model effective and valuable in many ways. It’s been shown to improve patient care and create better health outcomes. Some benefits include higher use of recommended therapies, fewer emergency department visits, shorter hospital stays and improved quality of life.

Over the years, the Chronic Care Model’s efficacy has been thoroughly studied. Patients generally receive better care and are more knowledgeable and empowered to manage their conditions. When practices address more domains of the model, they perform better on chronic illness care processes and outcome measurements. These changes are long-lasting, too, with most practices sustaining and even expanding them to new locations or conditions.

Still, the Chronic Care Model has its challenges, primarily due to cost structures within the US healthcare system that have historically favored fee-for-service care. The Centers for Medicare & Medicaid Services (CMS) implemented the Chronic Care Management program to address this difficulty and improve support for patients with chronic conditions.

Chronic Care Management’s Role in the Chronic Care Model

Providers can now receive monthly payments when delivering care coordination services to eligible Medicare beneficiaries. This change has helped many providers cost-effectively shift toward value-based care. It was rooted in the Chronic Care Model and offered a convenient framework for helping providers meet its principles. Since one of the most significant barriers to the Chronic Care Model is its financial viability, CCM reimbursement was an important step in the right direction.

CCM serves as a way to financially support providers as they aim to essentially reduce the number of patient visits, which would limit reimbursements under the fee-for-service approach. By paying providers for this preventive work, they can focus on improving population health overall and implementing a shared-savings strategy.

Like the Chronic Care Model, CCM is also evidence-backed. One study showed that, after a year, Medicare and taxpayers saved over $30 per patient per month after provider reimbursement. Enrolled patients saw a 4.7% reduction in hospitalizations and a 2.3% reduction in emergency department visits. With 72% of Medicare patients eligible for CCM programs, these savings and health benefits can add up. Here at ChartSpan, our customers saw savings of over $601 per patient per month — a whopping 712% more than the industry average!

CCM has also been evolving since it was introduced. Changes included adding codes for “complex” CCM, in which building the care plan requires a moderate or extensive amount of medical decision-making. This adjustment lets clinical staff spend more time on a complicated CCM plan and still get reimbursed for their efforts. In 2022, reimbursement rates increased considerably, offering further incentives to provide CCM care.

How ChartSpan Can Support Your Chronic Care Management Needs

Despite all of its benefits, CCM can be difficult to pull off. Many practices that struggle with CCM either lack the appropriate staff, don’t enroll enough patients to sustain the program or fall short in cost-effective billing practices. They may also lack organization or overload team members. ChartSpan helps practices overcome the biggest challenges of CCM and the Chronic Care Model so providers can focus on what’s important — delivering great care.

ChartSpan is proprietary CCM software and a fully-managed CCM service that works as an extension of your in-house team. We simplify the process of CCM by taking care of various tasks. We stay in touch, sending you regular reports and integrating with your EHR, so providers can easily access our findings within their clinical workflow.

Some of the things we can tackle include:

  • Patient communication: Whether we’re checking in on progress, asking about symptoms or organizing transportation, we’ll communicate with patients monthly to coordinate care according to your established goals.
  • General assistance: Our attentive team will help CCM patients take care of everyday tasks like refilling medication, making appointments, understanding test results and arranging home care, transportation or mobility resources.
  • 24/7 contact: An around-the-clock nurse line lets your CCM patients talk to an expert without increasing demand on your team.
  • Documentation: We follow robust documentation and tracking protocols to ensure every interaction gets recorded and you can maintain compliance.
  • Enrollment services: We’ll help you improve your CCM program by identifying eligible patients, conducting outreach, enrolling patients and optimizing billing for full reimbursement.

ChartSpan has helped a wide variety of practices thrive with CCM, including traditional practices, Federal Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs). We offer customizations to fit your organization’s size and scope and deliver the chronic care support your practice and patients need.

Master Your CCM Program With ChartSpan

CCM is an excellent route for implementing the Chronic Care Model, helping your patients improve their health and reducing costs for your practice. ChartSpan is the trusted solution for fully-managed CCM. We’ll tackle even the most challenging parts of CCM so you can spend more time on patient care. Our experienced team is committed to helping you reach your goals through attentive care and a wealth of patient data.

Reach out to us today to learn more and request your demo. See how our turnkey CCM program can help you implement the Chronic Care Model and improve patient care.

Jon-Michial Carter is the Co-founder and Chief Growth Officer of the largest managed Chronic Care Management (CCM) company in the United States,...

Published: August 4, 2022

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