Chronic Care Management (CCM): The New Player


Chronic Care Management is a program that is now covered through Medicare part B.

Working in pharmacy I have been taught that the future of pharmacy is going to revolve around medication therapy management (MTM). This is great and I believe pharmacists should play more of a role in patient outcomes by providing recommendations and spending individualized time analyzing patient’s profiles for potential problems. However, during my very last rotation as a pharmacy student I was introduced to another type of management program that is slowly beginning to creep up on MTM that you may or may not be aware of called chronic care management.

What is Chronic Care Management?

Chronic care management is a program that is now covered through Medicare part B. It offers patients that have multiple significant chronic conditions non-face-to-face services to improve patient outcomes. The program consists of talking to the patients for a minimum of 20 minutes per month where the pharmacist communicates with not only the patients but the other health care providers to coordinate care and offer the patients additional health services that they may need.

What Are the Requirements for Enrollment?

Patients must have 2 or more chronic conditions expected to last at least 12 months in order to enroll. Some of the chronic conditions that qualify include hypertension, dyslipidemia, heart failure, chronic kidney disease, diabetes, depression, arthritis, chronic obstructive pulmonary disease, Alzheimer’s, osteoporosis, cancer, atrial fibrillation, and stroke. If a patient meets this qualification and wants to enroll, Medicare requires an initial face-to-face visit with a billing practitioner where an extensive assessment will be conducted.

After the face-to-face visit has been conducted, Medicare requires you to obtain patient consent for CCM services, which can be either verbal or documented in the medical records. As a health care provider you will be required to discuss a number of things with the patient upon consent such as availability of CCM services and applicable cost-sharing and their right to stop CCM services at any point in time. It also must be known that only one practitioner can provide care and be paid for CCM services during a calendar month.

What Services Are Provided by CCM?

Chronic care management is actually very extensive and offers patients a wide variety of services that I will briefly discuss. CCM provides patients with 24/7 access to their physicians and other health care providers, which allows them to address whatever concerns they have regardless of the time of day. Providers will also create a comprehensive care plan for each individual patient based on physical, mental, cognitive, psychosocial, functional, and environmental aspects. This allows the health care providers to focus on all health issues the patient may have rather than just the chronic conditions already identified. A copy of the plan will be distributed to the patient and/or caregiver.

This program also helps individuals manage any care transitions that may take place when going between different settings whether it’s a referral to another physician or a discharge from the hospital. Health care providers will also perform medication reconciliations in order to make sure all of your prescription medications, over the counter products, and herbal supplements are up-to-date and on file. Having this information will reduce the potential for drug interactions and complications to occur.

What Does This Mean for the Future?

CCM is still relatively new and many health care providers still may not be aware of it. In the future we may see an increase in this service as studies have been conducted which concluded that this service decreased both hospitalizations and medical costs. Not only did CCM have an impact on finances but studies have also shown improved A1C values and an overall increase of quality of life. An average person may only visit the doctor a few times a year, chronic care management works with physicians, pharmacists, nurses, and other providers in order to manage a patient’s care in between those visits.


Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, et al. The expanded chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model. Hosp Q. .2003;7(1):73—82.

Centers for Disease Control and Prevention. Chronic diseases and health promotion. National Center for Chronic Disease Prevention and Health Promotion; 2010. Accessed May 4, 2017.

Piatt GA, Orchard TJ, Emerson S, Simmons D, Songer TJ, Brooks MM, et al. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care. 2006;29(4):811—7.

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