CMS launched the Chronic Care Management (CCM) program in 2015, in an effort to better coordinate care for their Medicare enrollees and for the purpose of bending the cost curve. CCM has been a strong force in Medicare’s preventative care efforts and has proven significant cost savings and improved outcomes.
Many providers fail to distinguish CCM from Case Management. Case Management is for patients with acute conditions who have become high utilizers of healthcare services (hospitalizations, emergency department care, etc.). This group typically represents the top 5-10% of Medicare patients and has the highest cost burden.
On the other hand, CCM is a program for Medicare patients who have two chronic conditions or more and is designed to prevent patients from becoming high utilizers of healthcare services. This group covers a much wider percentage of Medicare patients, at around 70%.
Differences Between Chronic Care Management and Case Management
CCM and Case Management are fundamentally and operationally quite different.
Patients are eligible for Medicare’s CCM program if they are a Medicare patient, have a history of two or more documented current chronic conditions, and have had a visit with their provider within the past year. Once the patient’s eligibility is established, they must personally consent to be enrolled into the program. Non-Medicare patients with two or more chronic conditions are not eligible to participate in CMS’ CCM program.
The eligibility process for a Case Management patient is much more complex and time consuming. The Certified Case Manager is required to conduct a thorough assessment of patient needs. Not only do they have to consider the patient, but they also have to take into consideration medical, legal and financial issues that may involve stakeholders. This is because the case manager is typically employed by a stakeholder such as a provider, payer or in the case of Medicaid run programs, a government entity.
When a patient is enrolled in a CCM program, he or she receives services to coordinate support for their health needs. This provides great value to the patient because information is synced between all of the patient’s providers, the program provider, and the patient. The purpose of this synergy is to provide preventative care – ultimately, joining all health forces together to keep the patient healthy and out of the hospital. CCM is intended to surround the patient with resources to maintain their current level of health and avoid it from declining. This is an important distinction.
Case Management is typically focused on managing acute episodes of a specific disease state, with the goal of preventing further progression of the disease. Case Management in the non-acute setting is typically focused on high-risk disease states (diabetes, asthma, CAD) where the focus is on monitoring and managing the utilization of resources required to achieve a stable state.
Case management typically requires monitoring of vital signs or other hands on (or remote) assessments of a clinical condition. On the other hand, CCM is a telephonic/virtual service. Common CCM activities include medication adherence, transportation assistance, SDoH and other preventative assessments.
- Financial Outcomes
CMS provides a reimbursement for providers to deploy a CCM program. The reimbursement runs an average of $47 per patient per month for traditional practices, and $67 per month for FQHC and RHC practices.
Case Management does not offer a reimbursement per patient. However, it does significantly enhance claims management by ensuring that all details of a hospital stay are medically necessary and delivered appropriately. This helps save the hospital and the patient thousands.
Although there are differences between the two, both programs are proven to reduce overall healthcare costs by improving patient outcomes and avoiding hospital readmissions.
- Professional Background
CCM can be performed by a variety of resources including and ranging from a clinical health coach to licensed providers.
On the other hand, multidisciplinary Acute Case Management teams are typically led by licensed Certified Case Managers whose backgrounds and training can be that of Social Workers or Nurses.
Similarities Between Chronic Care Management and Case Management
Although CCM and Case Management are quite different, they are founded around the same concepts.
- Similar Goals
Both programs were created to strive for the optimum level of wellness for patients in need.
- Education on Lifestyle Adjustments
CCM and Case Management professionals both work to educate their patients on how to improve their lifestyles. They can do this by recommending several health-related changes such as diet, exercise, and avoiding other detrimental habits, like smoking.
- Patient Planning and Follow-Up
In both programs, healthcare professionals create a personalized plan for each patient based on his or her health status and requirements. The professional then follows up with the patient throughout the timeline of the plan to make sure the patient stays on track.
- Health Monitoring
CCM and Case Management both focus on the patient’s diseases or conditions and/or impairments. Both will incorporate knowledge of current and past statuses of health. It is important to monitor each patient’s health journey because of potential changes caused by internal or external forces.
- Patient Outcomes
Both programs have been proven to improve patient outcomes and reduce the risk of readmission.
Once the similarities and differences between CCM and Case Management are distinguished, it is easy to see that both programs are important in their own ways. Neither is better or more important than the other because they both serve their own purpose. To maximize patient health outcomes, both programs are necessary components of healthcare in the United States. For practices and networks who are already doing Case Management, it is important to also consider a CCM program and its benefits.