Chronic Care Management (CCM)

Chronic Care Management (CCM)

CCM represents non-face to face care coordination for patients with multiple chronic conditions. CCM services include five core activities: recording structured data in a patient’s health record; maintaining a comprehensive care plan for each patient; providing 24/7 access to care; comprehensive care management; and transitional care management; Through CCM and complex CCM, the Center for Medicare & Medicaid Services (CMS) pays for
non-face-to-face care coordination services furnished to Medicare beneficiaries who reside in the community setting that meet the following requirements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline; and Comprehensive care plan established, implemented, revised, or monitored. With CCM, our clinical pharmacists can fill in the gaps in care when patients are not able to see their health care providers in person for an office visit. CCM provides extra revenue for primary care practitioners.

Potential CCM partners:
-Primary care practices
-ACOs
-PCMHs