5 Steps to Develop Your Chronic Care Management Program

By Srikanth
12 Min Read
5 Steps to Develop Your Chronic Care Management Program 1

Did you know that almost half of the adults in the United States are suffering from at least one chronic condition?


Apart from that, every 4 in 10 people in America are chronically ill with two or more chronic conditions. This has resulted in 86% of the healthcare cost attributed to chronic conditions alone. On top of that, the growing number of cases in the aging population is further increasing the pressure on healthcare providers.

This has made chronic care management programs a necessity for patients and providers to provide better care and reduce the overall cost of healthcare. But developing an ideal CCM program from your practice is easier said than done.

So, let’s help you with developing a chronic care management checklist for your CCM program in this blog post.

Why is the Chronic Care Management Program Important?

Living with chronic conditions is difficult, and the challenges it presents in performing day-to-day activities can sometimes be overwhelming. Furthermore, the growing number of chronic cases has increased the burden on healthcare providers significantly to meet the needs of every chronically ill person.

A CCM program is important to improve the quality of life for such patients and help them achieve health goals, manage medications better, and numb the effects of chronic conditions.

Though there are numerous benefits of a CCM program for patients and providers, it all drops down to its correct implementation for its success.

Checklist for Developing a Chronic Care Management Program

Developing a chronic care management program is complex, but if you have the right resources and plan, it can be a walk in the park. So, here are the six chronic care management best practices that you need to check when implementing the chronic care management software:

Step 1: Develop a Plan and Form your Care Team

5 Steps to Develop Your Chronic Care Management Program 2

The first and foremost step when it comes to developing a CCM program is to develop a plan for your practice. This basically involves all the logistics and resources that you need to run the program.

Along with that, you will need to train your staff with new responsibilities for managing the program smoothly. If you are confused about where to start, then designating care managers can be a first step in forming your care team. However, ensure that the plan includes managing enrollment, consent, and scheduling along with other activities that are essential to running the CCM program.

Step 2: Identify and Recruit Eligible Patients

Once the plan is set and the team is formed, the next step is to identify the patients eligible for your CCM program and recruit them. Before that, you need to check the criteria set by the Centers for Medicare and Medicaid Services (CMS) to check the eligibility of the patients. There are basically two conditions that the patient must have to meet the criteria:

  • The condition should extend for at least one year or until the death of the patient.
  • The patient must have at least two chronic conditions.

Identifying patients becomes fairly easy if you can leverage the power of EHRs to check which patients are eligible for the program. If not, using chronic care management software can come in handy.

Once the patients are identified, it’s time to recruit them. This can be done in three ways:

  • In-person: Higher conversion rate where you directly make the patient aware of the program.
  • Outreach Campaign: Outdoor marketing campaigns are also an effective way to reach out and recruit eligible patients for your program.
  • Phone Call: Another way of recruiting eligible patients is to make patients phone calls and make them aware of your program.

Step 3: Enroll Your Patients

After the patients have agreed to be a part of your program, it’s time to enroll them. Officially, you will need a written or verbal consent of the patient to be a part of your program. The complications usually arise in written consent, so make sure it has the following:

  • CCM overview and the patient’s consent
  • An explanation to discontinue the plan at any time.
  • A note that mentions that more than one provider can bill the patient for the service.
  • A note stating that the patient may have a copay option.
  • A note about the information shared with the physicians and how it will be used.

Step 4: Deliver CCM and Engage Patients

Once the patients are onboarded, you need to deliver care coordination and engage the patients with their care. The first thing to do in this is to create personalized patient-centric care plans. For this, your care managers can be helpful as they can easily connect with patients and assess their physical, mental, psychological, functional, cognitive, and environmental needs.

This also involves managing patients, which is usually their engagement. To gain high patient engagement, here are a few things that you must do:

  • Reminders and secure communication with the patient.
  • Facilitate coordination with all the members involved in the care team.
  • Providing ongoing updates on the patient’s care plan.
  • Ensure that the patient receives everything recommended on time without any delays.
  • Keeping a tab on patients’ treatment with medication adherence and constant communication.

Step 5: Coding, Billing and Reimbursement

Submitting claims through CMS must have the following five items:

  • CPT codes for each and every program you are offering.
  • ICD-10 codes are tied to each condition you are managing within the program.
  • Dates and time stamps of the service provided.
  • Place and mode in which the service is provided.
  • National Provider Identifier (NPI) number.

Here, it is important to verify the CMS requirements before submission to avoid any payment delays. Keep the process transparent by sending an invoice to the patient. Ensure that there are no conflicting codes that are being billed to avoid any further complications.


Developing a chronic care management program is tough, but it can be easily streamlined with the help of a chronic care management software solution. It not only streamlines most of the administrative tasks for your staff but also gives patients more control of their health. After all, that is the most important aspect of a CCM program.

Now that you know all the things you need to do to develop the ideal chronic care management program for your practice, let’s get this thing started!

Frequently Asked Questions

  1. What are the eligibility criteria for patients to participate in a CCM program?

The requirement for patients to qualify for the Chronic Care Management program is to have at least two or more chronic conditions that should last at least 12 months or till the patient’s death. Along with that, patient consent (either verbal or signed) is mandatory to start the program.

  1. What services are covered under a CCM program?

Some of the services offered under the CMS Chronic Care Management program are:

  • Medication Management
  • Patient Health Information Access
  • Care Coordination
  • Personalized Care Plans
  • Patient Education
  • Counseling and Patient Support
  • Clinical Care Management
  • Patient Engagement
  1. How do I determine the appropriate level of care for each patient in my CCM program?

Determine the appropriate level of care for each patient in the chronic care management program by creating personalized care plans, monitoring patient health vitals, assessing patient progress, and ensuring patients’ treatment adherence.

  1. What documentation is required for billing CCM services?

The documents required for billing CCM services are:

  • Patient Consent Form
  • Comprehensive Care Plan report
  • Dedicated 20 minutes per month to establish, implement, revise, or monitor the comprehensive care plan.
  1. How can I ensure my CCM program is compliant with all regulations?

To ensure compliance with your chronic care management program, you should check if all the rules and regulations set by the Centers for Medicare and Medicaid Services (CMS) are followed. Along with that, check for the compliance certifications of HIPAA, GDPR, or any other regulatory body.

  1. What are the different technologies I can use to support my CCM program?

Some of the technologies that you can use to support your CCM program are:

  • Remote Patient Monitoring Devices
    • Telehealth
    • Self-health managing medical apps
    • Electronic Health records
  1. How can I effectively communicate with patients and their families within the CCM program?

You can facilitate effective communication with patients and their families within the chronic care management software by using communication features like secure messaging, video conferencing, or audio calls using a telehealth platform.

  1. How can I measure the impact of my CCM program on patient outcomes?

The impact of the Chronic Care Management program can be seen in assessing the progress a patient has made after enrolling in the program. Some of the metrics to measure this are the level of patient engagement, medication adherence rate, and patient satisfaction levels.

  1. What are the potential challenges I may face in implementing a CCM program?

Challenges usually faced in implementing a chronic care management program are regarding managing time and resources, engaging patients, coordinating care, and streamlining billing practices.

  1. How can I get started with implementing a CCM program in my practice?

The first step to getting started with implementing the chronic care management program in your practice is assessing your patient population eligible for enrollment under the program and then successfully implementing chronic care management software in your practice.

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