An estimated 117 million adults have one or more chronic health conditions, and one in four adults have two or more chronic health conditions. Through the Connected Care campaign, the CMS Office of Minority Health and the Federal Office of Rural Health Policy at the Health Resources & Services Administration will raise awareness of the benefits of CCM for patients with multiple chronic conditions and provide health care professionals with resources to implement CCM.

​The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions. 

Less than 3% of all elegible Medicare Patients have enrolled in a CCM Program and less than 2% of all Providers have offered these services.

Below is a Typical Model of a Chronic Care Management Program

There is a recipe for improving quality that involves evidence-based guidelines , system change strategies and quality improvement methods. You are all familiar with evidence-based guidelines, so let’s start with the system change strategy.

 The Chronic Care Model (CCM) is an organizational approach to caring for people with chronic disease in a primary care setting. The system is population-based and creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team.

The CCM identifies essential elements of a health care system that encourage high-quality chronic disease care: the community; the health system; self-management support; delivery system design; decision support, and clinical information systems. Within each of these elements, there are specific concepts (“Change Concepts”) that teams use to direct their improvement efforts. Change concepts are the principles by which care redesign processes are guided. 

The items below are the change concepts associated with each component of the model that, when implemented, result in improved patient and system outcomes. 

  • A health system’s business plan reflects its commitment to apply the CCM across the organization. Clinician leaders are visible, dedicated members of the team.
  • Visibly support improvement at all levels of the organization, beginning with the senior leader. Promote effective improvement strategies aimed at comprehensive system change. Encourage open and systematic handling of errors and quality problems to improve care. Provide incentives based on quality of care. Develop agreements that facilitate care coordination within and across organizations.
  • Community resources, from school to government, non-profits and faith-based organization, bolster health systems’ efforts to keep chronically ill patients supported, involved and active.
  • Form partnerships with community organizations to support and develop interventions that fill gaps in needed services.
  • Advocate for policies that improve patient care.
  • Patients are encouraged to set goals, identify barriers and challenges, and monitor their own conditions. A variety of tools and resources provide patients with visual reminders to manage their health.
  • Use effective self-management support strategies that include assessment (physician or self?), goal-setting, action planning, problem-solving and follow-up.
  • Regular, proactive planned visits which incorporate patient goals help individuals maintain optimal health, and allow health systems to better manage their resources. Visits often employ the skills of several team members.
  • Define roles and distribute tasks among team members.
  • Use planned interactions to support evidence-based care.
  • Provide clinical case management services for complex patients.
  • Ensure regular follow-up by the care team.
  • Give care that patients understand and that agrees with their cultural background.
  • Clinicians have convenient access to the latest evidence-based guidelines for care for each chronic condition. Continual educational outreach to clinicians reinforces utilization of these standards.
  • Embed evidence-based guidelines into daily clinical practice.  Share evidence-based guidelines and information with patients to encourage their participation. Use proven provider education methods. Integrate specialist expertise and primary care.
  • Health systems harness technology to provide clinicians with an inclusive list (registry) of patients with a given chronic disease. A registry provides the information necessary to monitor patient health status and reduce complications.
  • Provide timely reminders for providers and patients. 
  • Identify relevant subpopulations for proactive care.
  • Facilitate individual patient care planning.
  • Share information with patients and providers to coordinate care.
  • Monitor performance of practice team and care system

So What Does All This Mean?

Successful system change means you will redesign care within each of the six components of the CCM; it does not mean tweaking around the edges of an acute care system not capable of handling the needs of the chronically ill. You will be building a new system that works in concert with your acute care processes. You will accomplish this by testing the above change concepts and adapting them to your local environment. The remaining steps in this manual help focus where you can start making these changes.

Tools That Can HelpAfter learning more about the chronic care model, there are two things that may assist you in understanding how it directs system change. The first is the Assessment of Chronic Illness Care, which is a diagnostic survey that you and your team can complete together. The ACIC helps you identify that current state of your chronic care; what’s working and what is needed to achieve redesign in all components of the CCM. 

The other tool is the ACT Report [PDF] (Shoeni, P. Accelerating Change Today: Curing the System, May 2002). This report provides concrete examples of teams that have redesigned their care based on the CCM. Some of the stories and the practices they represent may resonate with you and your team.

There Needs To Be a Quality Improvement Process

This is the final ingredient in the recipe. The Model for Improvement is a simple yet powerful tool for accelerating quality improvement changes in your organization. Developed by Associates in Process Improvement, the model has two parts. In the first part, your team will address three fundamental questions. These questions will guide your team in creating aims, measures, and specific change ideas. Secondly, your team will use Plan-Do-Study-Act (PDSA) cycles to allow these changes to be easily tested in your work environment.