• Patients
  • Providers

Chronic Care Management

Chronic Care Management is a Medicare benefit that gives patients access to a Health Coach to assist them in reaching their individual health goals. The outcome intent of the Chronic Care Management Program is to:

  • • Increase the patient’s quality of life
  • • Decrease hospitalizations and Medicare spending
  • • Increase practice efficiency
  • • Optimize practice revenue
  • • Keep patients connected to the physician practice facilitating strong attribution outcomes

Chronic Care Management is available to:

  • • Medicare beneficiaries with 2 or more chronic conditions 
  • • Medicare beneficiaries with conditions expected to last 12 months or the lifetime of the patient
  • • Medicare beneficiaries with conditions that place the patient at risk of death, acute exacerbation/decompensation or functional decline
  • The Chronic Care Management Program includes:
  • • Structured data recording
  • • A robust patient-centered care plan
  • • Electronic storage of the care plan and documentation in a certified EHR platform
  • • Provider electronic access to the care plan
  • • Care management services
  • • Thorough medication documentation and management
  • • Care coordination and communication

The Chronic Care Management program provides the ACO, Health System, Physician Organization, or Physician with reimbursement opportunity, closure of care gaps, medication management and reconciliation, coordination of care, and follow-on services opportunities. Just some of the immediate benefits of partnering with Life Line Community Healthcare for Chronic Care Management include:
  • • Reduce hospital and ER admissions through patient engagement and positive behavior changes
  • • Reduce preventable complications through thorough medication management and health coaching
  • • Improve patient clinical outcomes
  • • Improve quality measure capture
  • • Optimize practice efficiency by reducing unnecessary calls and office visits
  • • Optimize practice revenue through Chronic Care Management billing by the physician and follow-on services as a result of the CCM findings

It is important to understand why Chronic Care Management is important. According to the CDC, 3 out of 4 Americans 65 or older has multiple chronic conditions. As chronic conditions grow among the senior population, increases are seen in physician office visits, medications needed, and out-of-pocket costs. Even more concerning is the fact that 1 out of every 10 hospital stays are preventable with better management of chronic conditions, according to the Agency of Healthcare Research and Quality.