Can a healthcare provider create Chronic Care Management (CCM) plans for adult or geriatric patients with multiple chronic conditions, such as diabetes, hypertension, or heart failure?

Can Healthcare Providers Create CCM Plans?

Yes, healthcare providers can and should create Chronic Care Management (CCM) plans for patients with multiple chronic conditions—this is a reimbursable Medicare service specifically designed for beneficiaries with two or more chronic conditions expected to last at least 12 months or until death. 1

Eligibility and Requirements

Provider Eligibility:

• Any eligible Medicare provider (physicians, nurse practitioners, physician assistants, clinical nurse specialists) can deliver CCM services and create care plans 1
• Primary care clinicians or medical homes with associated healthcare teams are central to optimal implementation 2
• Multidisciplinary teams including nurses, pharmacists, and care managers should be involved in plan development and execution 2, 3

Patient Eligibility:

• Patients must be 65 years or older with two or more chronic conditions (such as diabetes, hypertension, heart failure, chronic kidney disease, dementia, or COPD) 1
• Conditions must be expected to last at least 12 months or until the patient's death 1
• Verbal consent is required from patients, who must understand their rights and any applicable cost-sharing 4

Core Components of CCM Care Plans

The care plan must incorporate these essential elements:

• Patient health priorities and preferences: Elicit what matters most to the patient regarding quality of life versus longevity, functional goals, and treatment preferences 2, 3
• Comprehensive condition inventory: Document all chronic conditions and how they interact, recognizing that treatment for one condition may worsen another 2
• Medication reconciliation: Complete review of all medications to reduce polypharmacy, assess complexity using tools like the Medication Regimen Complexity Index, and identify drug-drug and drug-disease interactions 3, 5
• Functional status assessment: Evaluate activities of daily living (ADLs) and instrumental ADLs, as functional limitations directly impact ability to benefit from interventions 5
• Prognosis estimation: Consider life expectancy (short-term <1 year, mid-term <5 years, long-term >5 years) to guide decisions about preventive interventions with long time-to-benefit 3, 5

Implementation Framework

Follow this structured approach when creating CCM plans:

1. Conduct comprehensive assessment: Review all chronic conditions, current medications, functional status, cognitive function, social support, and patient goals 3, 5

2. Prioritize based on patient preferences: Recognize that >50% of older adults have three or more chronic diseases, and single-disease guidelines may be harmful when applied cumulatively 2, 3

3. Document the care plan: Create a written plan shared with the patient that clearly articulates the role of each provider and the patient in the care process 1, 6

4. Provide ongoing care coordination: Conduct monthly follow-up calls or contacts to monitor the care plan, with at least 20 minutes of non-face-to-face care coordination time per month 1, 4

5. Ensure 24/7 access: Patients must have continuous access to care management services 4

Reimbursement and Financial Considerations

CCM services generate revenue for practices:

• Medicare reimburses for CCM services when documentation requirements are met 1
• Traditional Medicare patients have a copay (approximately $8.47 in 2020) 1
• Most patients with secondary insurance or Medicaid have copays covered, which increases participation 4
• Practices collected an average of $1,066 for CCM services in pilot implementations 1

Critical Pitfalls to Avoid

Common errors when creating CCM plans:

• Applying single-disease guidelines rigidly: Disease-specific guidelines may be cumulatively impractical or harmful for patients with multimorbidity 2
• Ignoring treatment interactions: Corticosteroids for COPD may worsen osteoporosis; statins for prevention may cause adverse effects that outweigh benefits in limited life expectancy 2
• Failing to assess time-to-benefit: Preventive medications may take years to show benefit, which may exceed the patient's life expectancy 5
• Overlooking patient preferences: Care provided without incorporating patient goals leads to poor adherence and increased treatment burden 2, 4
• Inadequate consent process: Patients must understand their rights and cost-sharing obligations before enrollment 4

Benefits Demonstrated in Practice

Patients participating in CCM services report:

• Better access to their primary care team and improved continuity of care 4
• Enhanced care coordination across multiple providers 4
• Peace of mind from having access to the CCM team 4
• Improved medical outcomes and treatment compliance in 72% and 56% of studies respectively 7
• Reduced health service utilization and cardiovascular disease risk 7

A common caveat: Some relatively healthy patients with two chronic conditions may question whether they need CCM services, suggesting that patient selection and education about benefits is important 4