How to Create a High-Performing, Patient-Centered Chronic Care Management Program
- Vipal Desai, MD
- Dec 4, 2025
- 4 min read
Chronic Care Management (CCM) performs much more than monthly calls. Even though CCM has been regarded as one of the best ways for practices to advance clinical outcomes and create sustainable relationships and revenues, success requires much more than a handful of phone calls. Monthly calls alone won't do the trick. This system requires a well-balanced collection of technology, trained staff, data analysis, real human relationships, and connection.
Whether you’re starting a program for the first time or trying to make the most of the one you have, basing your work on these recommendations will give you the best start possible for clinical quality, compliance, and patient trust.
1. Use Smart Tools to Identify Every Eligible Patient
The best CCM programs begin with accurate patient identification for the program.
In Enable Healthcare's EHI EHR - facilitated by Aria One AI - accurately pinpoints eligible patients using:
Payer type (Medicare & qualifying MA plans)
Last visit date
ICD-10 codes linked to chronic conditions
This takes away the guesswork, which avoids lost chances, and guarantees your CCM roster is accurate and compliant with CMS.
2. Use AI Tools to Gain Patient Insights & Personalize Care
Nurses do not get replaced by AI, and Enable Healthcare is a shining example of how AI tools enhance the role of nurses:
Enable Healthcare’s AI tools deliver:
Actionable patient insights
Risk flags
Trend detection
Care plan alignment recommendations
This freedom allows nurses to think more about specific patient needs, customize every call to the needs of the patient, and make sure that all goals of the care plan are being achieved.
The result?
This results in a more meaningful touchpoint, outcomes that are stronger, and that have better documentation for billing.
3. Personalize Every Care Plan
Patients stay engaged when their care plan feels like it's built for them, not copied and pasted.
Best practices:
Define goals based on clinical conditions and lifestyle realities
Update care plans as conditions change
Create education moments that match patient literacy
Encourage shared decision-making
Personalization increases trust—and long-term adherence.
4. Educate Providers & All Patient-Facing Staff
When your internal team understands CCM, your enrollment rate and overall success multiply.
Educate:
Providers
On clinical benefits, documentation, billing rules, and workflow.
Medical Assistants, front office, and support staff
On how to explain CCM, monthly calls, and patient benefits. To support this, Enable Healthcare provides:
QR code tent cards
Lobby posters
Handouts and brochures
These tools help introduce CCM before the conversation even begins.
5. Empower Patients Through Thoughtful Communication
Human connection drives the heart of CCM.
Key best practices:
Assign a dedicated nurse to build rapport month over month
Use staff who match the patient's primary language, dialect, or tone
Obtain clear, informed consent
Offer education that feels conversational and supportive
Patients engage more deeply when they feel heard—not rushed.
6. Leverage LPNs for Clinical Depth & Gap Identification
Enable Healthcare elevates CCM by having Licensed Practical Nurses (LPNs) conduct calls.
Why this matters:
LPNs bring clinical expertise
They identify gaps earlier
They escalate issues sooner
They enhance care plan accuracy
They document with clinical precision
This improves outcomes—and reduces risk for providers.
7. Use CMS-Compliant Care Coordination Charts
Enable Healthcare offers CMS-compliant CCM/RPM care coordination charts that:
Standardize documentation
Ensure every minute is accounted for
Support audit readiness
Keep clinical notes tightly aligned with CMS guidelines.
These charts make compliance simple and scalable.
8. Offer Fully Trained Staff as an Extension of Your Practice
Some practices lack the time or staffing to run CCM in-house.
Enable Healthcare provides:
Fully trained RNs, LPNs, and CCM specialists
A turnkey outreach team
Clinical documentation support
Real-time communication with providers
Seamless integration with the practice workflow
Our team becomes your team—without the hiring burden.
9. Use FTC-Compliant Communication Tools (No More “Scam Likely”)
Your calls can’t help patients if they never pick up.
Enable Healthcare uses FTC-compliant communication systems designed to:
Avoid “Scam Likely” labels
Improve answer rates
Maintain verified business caller ID
Follow all TCPA & FTC calling rules
Ensure safe, compliant outreach
This dramatically increases call connection rates—and patient trust.
10. Keep Monthly Topics Meaningful, Fresh & Relevant
A repetitive monthly call leads to disengagement.
Every call should include:
Clinical condition updates
Lifestyle + SDOH check-ins
Medication reviews
Specialist follow-ups
Personalized goal setting
Seasonal or condition-specific education
Variation keeps CCM valuable.
11. Integrate CCM With Other Key Services
CCM thrives when it works in harmony with the rest of your practice.
Integrate with:
Annual Wellness Visits
Routine follow-ups
Preventive screenings
SDOH resources
Medication refills & prior authorizations
This closes care gaps automatically—improving outcomes and revenue.
12. Document Thoroughly & Review Notes for Billing Compliance
Good documentation is good protection.
Nurses should:
Review prior notes before calls
Document in real time
Align conversations with the care plan
Track billable time accurately
Update conditions, changes, and new goals
This ensures CMS compliance and maximizes reimbursement.
Final Thoughts
A high-performing CCM program blends technology, staffing, and empathy into one seamless system. With AI-backed insights, LPN-led clinical calls, CMS-compliant charts, FTC-safe communication systems, and a fully trained support staff, Enable Healthcare helps practices offer exceptional care without adding workload.
CCM becomes more than a program; it becomes a lifeline of continuous support and a powerful extension of your practice.
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