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  • Writer's pictureRajat Chauhan

Step-by-Step Guide to Start Your Own Chronic Care Management Program

Updated: May 23

If you have opened this blog post, then you probably know about chronic care management and the influence it can have on care delivery for chronically ill patients.

The rising number of people suffering from chronic conditions has reached 103 million, which roughly makes up 42% of the American adult population. However, this is not the only reason for the Centers for Medicare and Medicaid Services (CMS) to start the Chronic Care Management program implementation in 2015.

Since chronic conditions were incurable, the pressure fell on healthcare providers to ensure these patients lived a long and fulfilling life. This doubled the burden on healthcare providers and institutions to provide continuous care to chronic patients. It not only increased the mortality rate but also the hospital readmission and emergency visits.

This directly affected the efficiency of the healthcare practices and proved to be a costly affair for both patients and providers. To solve this problem, CMS introduced the CCM program and allowed technology to take the lead in better care delivery.

In this blog post, we’ll walk you through a brief understanding of the CCM implementation in your practice!

Understanding Chronic Care Management

To start your own chronic care management program (CCM) implementation, let’s start from the beginning by understanding chronic care management. 

So, in a nutshell, a chronic care management program is a non-face-to-face healthcare service provided to patients with multiple chronic conditions. The aim of this program was to improve the life quality of the patients by preventing complications and enhancing patient-provider communication while reducing the overall costs of healthcare services.

But how do the providers get paid for the services they provide?

Well, that is when CMS saw it necessary to introduce Current Procedural Terminology (CPT) codes for reimbursements.

What is a CCM-Eligible Chronic Condition?

With a high number of the adult population suffering from chronic conditions, it can be a little daunting to provide chronic care under the CCM program to all. That is why CMS has set some of the patient eligibility criteria. 

  • Patients eligible for CCM should have at least two chronic conditions, which are to last at least 12 months or until the patient’s death. Patients at a significant risk of death, functional decline, or acute exacerbation are also eligible for this program.

  • Though the CCM program typically does not involve face-to-face consultation, the first day of the program needs to be a face-to-face interaction.

  • Furthermore, the eligible practitioner needs to spend at least 20 minutes of care coordination services per month.

  • Billing practitioners must bill the patients for the CCM services as suggested in CPT guidance.

  • There is no set number of chronic conditions that the patients should have; however, some of the conditions that are often included in a CCM program are:

  • Alzheimer’s Disease

  • Arthritis

  • Asthma

  • Cancer

  • Depression

  • Diabetes

  • Hypertension

  • HIV and AIDS

  • Cardiovascular Diseases

How do you start your own chronic care management (CCM) program implementation?

Now that you’ve covered all the basics about the program let’s start the CCM implementation step-by-step guide below.

  1. Identify your Goals and Patient Population

The first step to starting your CCM program is to identify your goals and the patient population you will be serving. Identifying your goals loosely translates to setting the aim of your CCM program. The most common goals for CCM programs are reducing the burden on healthcare providers and providing better care to chronic patients. Here, identifying the diseases that you can effectively monitor virtually can help you align the further processes of the program.

Furthermore, to determine the patient population for the CCM program, you can use EHR to identify the eligible patients. 

2. Patient Enrolment

Once you have identified the patient population for your healthcare program implementation, it is now time to make the eligible patients aware of the program and then onboarding them. For creating awareness, the best practice used by practitioners is face-to-face direct consulting about the program. Some of the other means, like direct text messages and outdoor marketing, can also be used to create awareness about the program. However, to successfully onboard the patient on the program, you will get written or verbal consent from the patient stating that they are ready to start the program with you.

3. Incorporate Remote Patient Monitoring Technology

Once the patients start entering your program, it is time to incorporate RPM technology into your program, as it enables you to collect important patients and monitor them remotely. Since you already identified the diseases you’ll be covering in your program, it’ll be easy for you to choose which devices you need and define the care cycle accordingly.

4. Comprehensive Care Plan to Manage Chronic Conditions

Develop a comprehensive care plan for all the health conditions you are planning to cover in your CCM program and focus on managing chronic conditions for patients. Define the workflow of your clinical practice to effectively manage chronic conditions and the patients that are enrolled in the program.

5. Assess the Patient’s Needs

Personalized care is one of the core aspects of chronic care management. Here, assess the individual needs of the patients and set a comprehensive care plan to achieve those goals. Have a holistic approach while assessing their needs and consider medical, functional, and psychological needs to curate a responsive care program.

6. Establish a Care Team with Defined Roles and Responsibilities

While you are doing all these things, to keep the CCM program running effectively, establishing a care team dedicated to that program is essential. Assign care managers (care managers should be certified nurse practitioners or other care providers as stated by CMS) and other members in the care and define their roles and responsibilities for the success of the program. Also, provide them with effective training with the chronic care management software and the workflow in providing virtual care.

7. Establish Protocols for Care Plan Triggers

Since most of the part of a CCM program relies on data collected from RPM devices, it is important to develop standardized care plans and protocols to ensure consistent care delivery. Collaborate with the care managers and take into account different factors like treatment plans, patient preferences, and care goals to improve patient health outcomes.

8. Patient Communication and Engagement

24/7 access to care facilities is also one of the major factors in the healthcare program implementation. To ensure that, make sure that your chronic care management software includes all the necessary features to keep the patients engaged with their care. Some of the essential features that you must consider are Appointment scheduling, secure messaging, and access to educational resources.

9. Coding and Billing for Chronic Care Management

There are specific CPT codes and documentation required by CMS to provide reimbursement for CCM services. The CPT codes involved are CPT 99490, CPT 99439, CPT 99487, CPT 99489, CPT 99491, and CPT 99437. The documentation needed for reimbursement is a comprehensive care plan, patient consent, and EHR documentation.

Our Platform

While you are looking to start your own chronic care management program, you will need robust chronic care management software that will not only meet all your needs but also enhance your CCM program practices. Click here to request a demo of our platform and how it can bridge the gaps in your CCM program.


There are a lot of things to consider when you are starting your own CCM program. Since it deals with patients who need continuous monitoring, every aspect of this program becomes even more important. Let this blog be your step-to-step guide to starting your CCM healthcare program implementation and improving the quality of life for your chronically ill patients.

Frequently Asked Questions (FAQs)

  1. Who is eligible for a CCM program?

Patients who have two or more chronic diseases which are expected to continue for at least 12 months or until the patient's death are eligible for the Chronic Care Management Program.

2. What services are covered under CCM?

Some of the services offered to patients with multiple chronic conditions enrolled under the CCM program are:

  • Medication Management

  • Clinical Care Support

  • Care Coordination

  • Care Management

  • Personalized Care 

  • Patient Education

  • Patient Health Monitoring

3. How do I determine the appropriate level of care for each patient?

The appropriate level of care for each patient can be determined by providing better care services offered in your CCM program. These services include creating personalized care plans, monitoring patient vitals, tracking patient progress and treatment adherence levels.

4. What documentation is required for CCM billing?

Some of the documentation requirement for CCM billing are:

  • Patient consent form

  • Comprehensive care plan document

  • Patient proof for multiple chronic conditions

  • Dedicated 20 minutes of time spent on providing care service such as establishment, implementation, adjustments and monitoring patient health with respect to the decided care plan.

5. How can I ensure my CCM program is compliant with regulations?

Check if you have adhered to all the rules and regulations set by the Centers for Medicare and Medicaid Services (CMS). Along with that, also check if the compliance certifications like HIPAA, GDPR or other with the software vendor.

6. What technologies can support my CCM program?

Here are some technologies that support the chronic care management program:

  • Remote Patient Monitoring Devices

  • Telehealth Platform Integration

  • Self-health Managing Medical Application like eCareMD

  • Electronic Health Records (EHR) Integration

7. How can I effectively communicate with patients in a CCM program?

Using effective real-time communication features like secure messaging and harnessing telehealth platform’s features like video conferencing and audio calls to facilitate communication with chronic patients with chronic care management software.

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

The best way to measure the impact of your CCM program is to check patient adherence with the treatment, patient engagement with their care activities, and tracking patient progress with respect to the pre-defined patient health goals.

9. What are the potential challenges of implementing a CCM program?

During the implementation of your CCM program you can face potential challenges regarding managing time and resources, driving patient engagement, coordinating care with care team members and streamlining billing and reimbursement processes.

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

To get started with the implementation of your CCM program in your practice, the first step is to assess the eligible patient population that can be enrolled in your program and then successfully implement Chronic Care Management software in your healthcare practice.

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