Chronic Care Management (CCM) is a Key Constituent of ‘Virtual Health’ Enabling Patient-Centric Care

Chronic Care Management (CCM) is a key constituent of ‘Virtual Health’ enabling Patient-Centric Care. CCM is a catalyst in reducing costs across healthcare systems. CCM also increases the revenues of practices at $44 per patient per month.

  • Over 90% of all healthcare spend goes toward treating people with chronic conditions.

  • Improving health leads to prevention of secondary complications, reduction in emergency room visits, hospitalizations, and readmissions.

  • CCM is a proven option that helps manage patients with chronic ailments between office visits.

Half of all patients readmitted to hospitals within 30 days had no or minimal post-discharge contact with healthcare professionals. Patients with multiple Chronic Conditions have better outcomes when they are given tools to promote better self-care and have a skilled resource to help coordinate care between multiple providers.


Patients receive better continuity of care when a practice develops a holistic view of patient’s needs related to functional, social, physical, and mental health and provide a point of regular contact for the patient. CCM addresses this gap in care by managing patients between office visits.


Chronic Care Management assists in care coordination by:

  • Engage in monthly patient contact

  • Communicate, engage and monitor patients by clinical staff

  • Encourage patients to follow physician-approved care plan

  • Discuss, direct and assist Patients with socio-economic requirements

  • Periodic Medication Reconciliation, assistance with refill requirements; review of adherence and interactions; document any OTC medication consumed

  • 24x7 access to clinical staff

  • Schedule appointments for follow up visits

Greater vigilance by patients with chronic conditions is not difficult and can be a key to healthier outcomes with lower costs. In addition, these “care beyond the walls” programs prevent complications and costly interventions.


CCM Eligible Chronic Conditions:

There are over 50 chronic conditions that are eligible for CCM Services.

  • Addiction/substance abuse Alcoholism Opiate abuse

  • Autoimmune diseases Osteoarthritis Rheumatoid arthritis

  • Blood disorders Anemia Leukemia

  • Cancer Breast cancer Colorectal cancer Prostate cancer

  • Cardio-metabolic conditions Congestive heart failure Diabetes Dyslipidemia

  • Chronic pain Resulting from diseases in various therapeutic areas, e.g., autoimmune diseases, cancer

  • Endocrine disorders Addison’s disease Hypothyroidism

  • Eye conditions Cataract Glaucoma

  • Gastrointestinal diseases Crohn’s disease Gastroesophageal reflux disease

  • Infectious diseases Hepatitis C HIV

  • Kidney diseases Chronic kidney disease End-stage renal disease

  • Lung diseases Asthma Chronic obstructive pulmonary disease Emphysema

  • Mental disorders Bipolar disorder Depression

  • Neurological diseases Alzheimer’s disease Multiple sclerosis

  • Urologic diseases Benign prostatic hyperplasia, Interstitial Cystitis



42 views0 comments