Chronic Care Management – Its Benefits Down to the Road in the Digital Healthcare Industry

With the changing dynamics in Healthcare Industry, from robust improvements in medical regulations to varied technological solutions; Chronic Care Management (CCM) is the talk of the town. Ironically, healthcare practices are on the edge when dealing with the patients’ chronic health conditions. Without any debate, chronic health conditions get heavy on pockets for the healthcare industry. It is where digital health has played a significant role in rescuing the monarchy.

Talking about patients with chronic diseases, particularly healthcare, doesn’t stop at the practise or hospital’s door. That’s the reason Centres for Medicare or Medicaid Services (CMS) apprehends Chronic Care Management (CCM) as a significant ingredient for primary care, which acts as a support system for patients outside the clinic.   

CCM – Benefits down the Road

CCM deals with Care Coordination Services, known as CCS, that are digitally handled other than the patient’s regular visits to the clinic. The patients with two or more chronic conditions that might last for 12 or more months or until the patient expires or is at greater risk of death and have Medicare insurance are enrolled in this service. These CCM services include telephonic communication with the patients. Additionally, it permits all the eligible practitioners to bill against their 20 minutes or 60 minutes for monthly correspondence. According to CMS, CCM is one of the critical components of primary care that significantly aids in the betterment of the patient’s health.


Chronic Care Management provides a window of opportunity to increase the practice cash flow while empowering patients to self-analyze and manage their health conditions and take appropriate actions accordingly for a better health outcome. Consequently, it enhances the patient’s ability who are eligible for Medicare Fee-For-Service (FFS) beneficiaries. Mainly, for CMS and other private insurance payers, it is of great significance to recuperate, enhance and improve patient’s care delivery and health results for the individuals with chronic diseases. CCM also helps to stay in touch with these patients who visit their medical provider office once a year.

Preliminary studies show that appropriate and systematic initial health appraisals, such as a Medicare Annual Wellness visit, customized healthcare plans, medication management, and a consultation call from a trained health coach, can improve patient’s health outcomes and minimize the abrupt clinical events.

The reduction of anticipated and emergent patient needs contributes to an overall healthcare cost reduction for both the payers and the patients. The telecommunication, digital patient’s access, and care being provided and effectively executed also throw abundant opportunities to enhance patient experience and contentment.

Chronic Care Management
Chronic Care Management

At NEO MD, in our CCM department, we analyze and go through patients’ medical records to see how badly their health condition is and how the CCM program can help them improvise their health goals and overall life quality. Rapport building with the patients on behalf of the medical providers and help the doctor’s office know the patient’s mental/physical health As a part of CCM, one crucial thing is medication reconciliation. 

NEO MD offers comprehensive CCM consulting services:

  • To devise a roadmap for CCM
  • To assign a dedicated CCM coach
  • To check eligibility of chronic care management patients
  • To prepare chronic diseases related questionnaire
  • To acquire verbal consent
  • To schedule calls on monthly basis and complete the required minutes
  • To send the clinical documents for further reviewing
  • To enter the data in EHR as per CCM encounter

In a nutshell, CCM has made it easier for the patients and providers to get into a chain of communications and digitally available information accessible to patients to avoid inconveniences. Yes, it has changed the digital healthcare paradigm. But unfortunately, it tangles a few barriers along, particularly for this part, and I have the following blog lined up!

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