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What is Chronic Care Management and how it Works?

Chronic care management or CCM as it is commonly referred has steadily become a too important and almost irreplaceable part of modern healthcare. As the ageing population with their chronic health difficulties and conditions now makes a large portion of regular healthcare customers, improving day to day patient care utilizing modern methods and technologies became a need.  In this context, Chronic Care Management (CCM) has a great role to play in elevating healthcare standard and better patient care.

What is Chronic Care Management (CCM)?

Chronic care management refers to the non-face-to-face or background services provided for healthcare patients suffering from multiple chronic diseases or health conditions. The services under this healthcare management category include coordination of communication with the patient and responsible health professionals by both electronic means through other means of communication like telephone, management of medication and treatment and assuring round the clock patient care and monitoring.

Key components and responsibilities involved in Chronic Care Management

Electronic care plans is always a key component of chronic care management.  The responsible CCM clinician establishes implements, revises, monitors and manages the following aspects.

• Electronic care plan addressing various aspects and requirements of the patient pertaining to physical, mental, cognitive, psychosocial, functional and environmental needs.

• Maintaining and supervising the inventory and resources for meeting patient care needs.

• Maintaining a certified Electronic Health Record for billing with the respective CCM code.

• Billing for a patient by coordinating with other subordinate specialists responsible of care and treatment to one or number of patients.

• Patient care coordination and round the clock monitoring and support are the two most important pillars of chronic care management.

• The electronic methods and dynamic plans for meeting variety of patient needs and situations of coordination is also one key element.

Services from a designated CCM service provider

A CCM service provider exposed to state of the healthcare practice and technology will cover the following areas of service.

Patient care coordination:

Patient care coordination is the prime objective of chronic care management. Especially for assuring stable and responsive to patients with chronic and permanent illness the coordination plays a crucial role. Getting the best treatment depends on how quicker you get in touch with the specialized doctor and background coordination among clinical professional just assures that. Here below are the key elements of patient care coordination.

• Contacting and getting treatment from specialized doctors through coordination from a dedicated team of professional clinicians.

• From a doctor’s visit to medical tests to any medical event related to patient care integrated into a workflow.

• Medical history and patient information is verified and shared among the doctors and nurses.

• Doctor appointments and reappointments are verified and scheduled at the earliest.

• Checking doctor’s availability and facilitating emergency care.

Dynamic and electronically updated patient care plan

Now with the widespread implementation of electronic healthcare data management systems and apps sharing, exchanging and providing clinical data for better coordination in treatment has become easier than ever before. Let us look at some key aspects of patient care coordination through dynamic and electronically updated care plans.

• Exchanging clinical summaries comprising medical history and patient information through electronic interfaces.

• Exchanging care plans for patients through electronic interfaces.

• Regular plan management through updating, reviewing and verifying results against treatment objectives through the use of electronic software and apps.

Round the clock support

Finally, the most important aspect of an expertise driven committed CCM service is the round the clock availability and dedicated support.

• 24x7 support and assistance in a prompt manner.

• Prompt responsive mechanism to deal with any medical emergency.

• A really useful mobile app for all parties involved.

• Electronic mechanism to make medical information available for the purpose of billing.

Chronic care management is evolving with electronic interfaces and apps to make patient care more responsive, time bound and prompt. With the ease of communicating medical data and records overall care coordination is continuing to get better.


Oculus Health has developed a medication tracker app for personal health management which enables care team and doctors to provide the patients with the right treatment at the right time to improve patient engagement and meet Medicare’s chronic care management needs. To read more about chronic care management, visit Wikipedia.

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