CCM
Chronic Care Management
Chronic Care Management supports patients living with multiple chronic conditions through a documented care plan, regular engagement, and coordination with the patient's care team between visits.
Assess CCM for your organizationScoped workflow
How CCM works
Illustrative workflow. Specific responsibilities are agreed with each organization.
- 01
Identify
Patients who may be eligible are identified with the practice.
- 02
Consent & enroll
The patient is informed about the program and consent is captured.
- 03
Care plan
A comprehensive care plan is developed and maintained with provider oversight.
- 04
Engage
Recurring check-ins address goals, barriers, and questions.
- 05
Coordinate & document
Care-team communication and time spent are documented.
Program considerations
Care planning
The care plan is the backbone of CCM: problems, goals, interventions, and responsible parties. It is created and updated under provider direction and shared with the patient.
Engagement and coordination
Between visits, patients receive structured outreach to review progress, surface barriers, and coordinate with other providers or community resources. Medication-related activities are included only where within the agreed scope.
Documentation
Enrollment alone does not establish billable activity. Each interaction and the work performed must be documented in a way the practice can review.
Implementation, documentation, and coverage
Implementation steps, documentation standards, and reporting formats are agreed during scoping. Coverage and reimbursement vary by payer, patient, service, documentation, and applicable requirements.
Common questions
How is CCM different from PCM?
CCM addresses patients with multiple chronic conditions through a comprehensive plan. PCM focuses on a single complex, high-risk condition.
Can CCM be combined with RPM?
Some patients may participate in more than one program when clinically appropriate and permitted by applicable requirements. Combinations are reviewed individually.
Is CCM right for your patients?
Discuss program fit, responsibilities, and implementation with Kare.