How Chronic Care Management Changes the Patient Experience: An Overview
Even though chronic disease is complex and life-altering, it shouldn’t turn the chronic patient experience into a continuous and overwhelming crisis. However, millions of Americans experience a life crisis and reactive healthcare consisting of a chaotic schedule of appointments and multiple medical emergencies.
Chronic Care Management (CCM) is the opposite of this. CCM offers Americans with chronic and ongoing health conditions the continuous support and coordination efforts needed to reduce the need for larger critical interventions that come with proactive episodes of urgent care.
The Cost of Chronic Disease in the United States
Unfortunately, we are in a health care crisis and the statistics are sobering.
Approximately 133 Million Americans, or 60 % of the population, live with at least one chronic condition.
90 % of the United States’ 4.1 trillion dollars of annual health care spending is on chronic disease management.
70 % of the death in the United States are from chronic diseases.
86 % of the healthcare costs in the United States are from patients with chronic conditions.
Given these healthcare-related statistics, it is easy to see that the care chronic disease patients actually need is virtually nonexistent.
The experience of the patient with chronic disease in this care model is as follows.
One of the expectations of the patients in these systems is seen every 3 to 4 months. Each 15-minute appointment is packed with reviewing the patient’s record, some medication adjustments and instructions are given, and then the patient is left to navigate and care for themselves until the next appointment.
Between visits, you are expected to:
Take multiple medications correctly.
Monitor your symptoms and vital signs.
Follow complex diet and exercise plans.
Communicate between multiple specialists.
Know when symptoms require immediate action.
Deal with insurance and prescriptions.
When something does go wrong, and it often does, you can go to the ER or get hospitalized and start the whole cycle over again.
Learn More: Understanding Evaluation and Management in Medical Billing shows how better support for chronic, continuous care can be achieved.
What Makes Chronic Care Management Different?
CCM replaces this reactive, episodic model with continuous, proactive support built around what patients with chronic diseases actually need.
The Chronic Care Management Framework
Traditional Care
Doctor Visit – Go Home Alone – Crisis – ER/Hospital – Crisis – Repeat
Chronic Care Management
Doctor Visit – Support System – Early Problem Detection – Proactive Intervention – Better Health
Main CCM Activities
✅ Assigned Care Coordinator – Your healthcare point of contact who understands your entire health history
✅ Monthly Health Check-Ins – Evaluation that recognizes issues in the beginning phase
✅ 24/7 Access to Care Team – Professional help all day every day
✅ Personalized Care Plans – Customized approach for your specific case
✅ Multi-Provider Coordination – Effortless interaction among all your healthcare providers
✅ Medication Management – Assistance for intricate treatment plans
✅ Patient Education – Information and tools to manage medical conditions in a self-directed manner
10 Ways CCM Delivers Better Patient Outcomes
1. Prevention of Patient Hospital Admissions and ER Visits Increased by 20%
The Evidence
CCM programs have been shown in studies to decrease the number of hospital admissions by 20% and ER visits by 13%.
Why This Happens
By performing check-in appointments monthly, staff are able to mitigate events that can easily escalate.
Take, for example, the following months of events:
Week 1: Patient mentions increased shortness of breath during a routine check-in
Week 2: Care Coordinator notices weight gain and goes over other symptoms with the patient.
Week 3: Physician adjusts diuretic dosage based on the report from the care coordinator.
Result: Hospitalization is avoided, and heart failure exacerbation is prevented.
Real Patient Stories
74-year-old James, with heart failure, enrolled in CCM after having 4 hospital admissions in a single year. James learned from his medical care coordinator how to monitor daily his weight and symptoms. After a 5 pound weight gain in 3 days, he was able to avoid his 5th hospitalization by having a medication adjustment made. James has been in CCM for 18 months and has not been hospitalized during that time.
Real Patient Stories
The Financial Impact
The average cost of a single hospital stay: 12,000−15,000.
The average cost of a single ER visit: 1,500−3,000.
The average monthly cost of CCM: 40−60.
By preventing a single hospitalization, 5 or more years of CCM services are paid for.
2. Doubles Medication Adherence Rates
The Problem:
Medications are not taken as prescribed by half of all patients with chronic illnesses. This results in 125,000 unnecessary deaths and an annual loss of $300 billion in healthcare resources.
How CCM Solves This:
Education That Makes Sense:
This medication protects your kidneys from damage caused by diabetes.
Not just: Take this pill twice daily
Simplification:
- Collaborating with the physician to potentially decrease pill burden.
- Aligning the medication schedules with daily routines.
- Addressing cost barriers with assistance programs.
Ongoing Support:
- Regular adherence checks in monthly contacts.
- Problem-solving with patients when side effects are an issue.
- Providing reminder systems tailored to each person.
Measurable Results:
CCM participants show 30-40% improvement in medication adherence to:
- Better symptom control
- Fewer complications
- Reduced complications
- Slower disease progression
- Lower rates of hospitalization
Success Story:
Maria had 8 medications for diabetes, hypertension, and cholesterol. She often confused her doses and timings of drugs, and missed some medicines for days. Her care coordinator made a color-coded chart, coordinated pharmacy refills, and organized her medications into weekly pill boxes. In 4 months, her A1C dropped from 9.5 to 7.2 and her blood pressure stabilized.
3. Transforms Passive Patients into Empowered Partners
The Shift: From Passive Recipients of Care to Active, Informed Health Managers
Empowerment through Knowledge
- Understanding why your A1C number is important.
- Knowing what the early warning signs of complications look like.
- Recognizing what signs need to be addressed.
- Understanding why treatments are important and how they work.
Empowerment through Skill
- Knowing how to take & record your blood pressure or blood glucose.
- Being able to read food labels & make healthier choices.
- Effectively manage symptom tracking.
- Clearly articulate health concerns to your provider.
Empowerment through Confidence
- Feeling like you can manage your health until the next appointment.
- Asking questions without fear of consequence.
- Making choices about your healthcare.
- Being able to defend your position and requirements.
The Research Show
- Engaged patients show:
- 40% Better Clinical Outcomes
- 50% Fewer Hospitalizations
- Lower Cost of Care
- Increased Satisfaction with Care
- Higher Overall Satisfaction
- Improved Overall Quality of Life
- Lower Overall Health Risk
- Increased Competence & Self-Efficacy
4. Reduces the Confusion multi-Disciplinary Care Causes
The Problem:
Patients with chronic illness often see:
- 1 Primary Care Physician
- 2-3 Specialists
- Various Ancillary Providers (Physical Therapist (PT)), Nutritionist, Mental Health)
- Multiple Pharmacies and Laboratories
Without coordination, the following issues often arise:
- Specialists may prescribe conflicting medications
- Not all providers get all the test results
- No one has all the relevant information
- Patients have to repeat their health information over and over to each new provider
- Important follow-up meetings may be missed
How Care Coordination Works:
Your Care Coordinator functions as the information hub and ensures:
- All providers have up-to-date information
- There are no conflicting medications from various doctors
- All relevant parties get test results
- Appointments are organized
- Post-hospital follow-up meetings occur within the correct time window
- Referrals are completed and tracked
Example of Actual Coordination:
Robert sees a Cardiologist, Nephrologist, and Endocrinologist for his complicated conditions. After his Cardiologist prescribed a new blood pressure medication, Robert’s CCM coordinator noticed the medication could worsen his kidney function and interact with one of his diabetes medications. She organized a consultation with all three providers to discuss and prescribe an alternative medication that is safe for all of Robert’s conditions. Without this coordination, one of the possible outcomes could have been an acute kidney injury.
5. Prevents Complications Before They Happen
Preventive Measures in Proactive Care:
Proactive Care is unlike standard care. Proactive Care encompasses prevention of complications rather than managing them post-incident.
Pathology Screening:
Retinopathy is one of the most harmful complications of diabetes. CCM covers annual diabetic eye exams.
Kidney failure is an outcome of diabetes, and diabetes is also one of the main risk factors. Preventive kidney function tests are essential.
Diabetes doubles an individual’s chances of experiencing a heart attack. Hence, diabetes puts people in the high-risk category for a cardiovascular event.
Mental illness is also known to complicate the management of chronic disease. Hence, regular depression screening is an essential component of proactive care.
Chronic illness can complicate the management of one’s disease. Hence, proactive care covers regular bone density tests.
Monitoring:
Proactive Care monitors the average of blood sugar readings rather than only single readings.
Proactive Care monitors blood pressure patterns rather than single readings.
Proactive Care also monitors sustained weight gain.
Proactive Care monitors the progression of previously diagnosed symptoms and the development of new ones.
Intervention:
Proactive Care makes medicine adjustments before the need for crisis interventions.
Proactive Care modifies interventions before the need for escalation.
Proactive Care makes timely specialist referrals.
Proactive Care intensifies interventions when necessary.
Integration of Preventive Care: Proactive Care integrates services and provides year-round preventive care.
The Impact of Early Detection:
| Complication | Cost to Treat | Cost to Prevent |
|---|---|---|
| Diabetic amputation | $50,000-$100,000 | $500-$2,000 |
| Heart attack | $20,000-$50,000 | $1,000-$3,000 |
| Stroke | $40,000-$100,000 | $1,000-$5,000 |
| Kidney failure/dialysis | $90,000/year | $2,000-$5,000 |
6. Obtaining Maximum Control Over Long-term Illnesses
The Proof
Research shows that people partake in Controlled Care Management Programs (CCMs) and have significantly better control over chronic diseases and have a higher chance of not having complications from diseases.
Improvement Within All Illnesses
Diabetes
CCM’s diabetes management has proven to lower A1C levels 1-2 points on average. CCMs also decrease dangerous blood sugar swings, decrease emergency episodes, and increase time in the target range.
Hypertension
On average, CCMs decrease blood pressure 10-15 mmHg, decrease blood pressure swings, and decrease the risk of cardiovascular events.
Heart Failure
With heart failure, CCMs have proven to decrease the number of episodes of fluid overload, decrease hospital readmissions by 25%, increase exercise tolerance, and increase quality of life scores.
COPD/Asthma
With chronic obstructive pulmonary disease, CCMs have proven to decrease the number of exacerbations by 30%, decrease reliance on rescue inhalers, increase lung activity, and daily activity levels.
The Long-term Effects
Having better control over disease results in a slower disease progression, and the complications that come with chronic diseases are less organ damage and better functional independence. People also have a longer life and a reduced risk of dying from chronic diseases.
7. Provides Round-the-Clock Expert Access
Being Able to Reach Someone Anytime
Knowing you can reach a healthcare professional anytime, whether it’s 3 AM, a Sunday afternoon, or a holiday, alters the experience of dealing with a chronic illness.
When 24/7 Access is Important:
Urgent Issues:
- What do I do if my blood sugar is 300?
- Do I need to go to the emergency room? I have chest discomfort.
- I think I took my medication more than once.
- My leg is swelling. Should I go to the ER?
Non-Jurgent, But Important:
- Medication side effects that need attention.
- Confusion about the new instructions provided by a specialist.
- Questions regarding how to manage your health during travel.
- Concerns about symptoms that you have that aren’t severe, however, they are worrisome.
How it Stops Unnecessary ER Visits:
A member of the CCM team can:
- Assess your symptoms from a distance
- Figure out if your symptoms are an emergency or what level of care you would need
- Provide instructions on how to manage your symptoms at home if it’s safe
- Schedule an urgent appointment, however, not an emergency, when available
- Communicate with the on-call physician if needed
For your safety, while CCM offers guidance, the situation may need to be urgent. Your care team will help you figure out the most appropriate level of care.
True Effects on People’s Lives:
Around 11 PM Saturday, Linda felt dizzy and nauseous after having taken her medication for blood pressure. Instead of waiting for Monday or worrying, she decided to call her CCM hotline. One of the nurses went through her medications and noticed she had taken a double dose. told her to skip her morning dose and set her up for a check-in for the next day. No need to go to the emergency room, no more anxiety, problem solved.
7. Gives 24/7 Expert Access
How Customers Are Affected Personally
Being able to reach out to someone trained in healthcare, day or night, 365 days a year, profoundly alters the dynamics of living with a chronic illness.
Response to the Customer’s Questions
Questions that require an urgent answer
- What should I do if my blood sugar is 300?
- Should I be worried if I’m having chest discomfort?
- Should I go to the ER if my leg is swelling?
- I think I may have doubled my dosage of my medication.
Questions that require an answer but are not urgent
- What should I do about my medication’s side effects?
- I don’t understand some of the directions I was given by my new specialist.
- Can I manage my other illness when I go on a trip?
- I have some symptoms that I’m not too worried about, but I do have some other concerns.
How You Can Avoid Most ER Visits
One of the team members that you’re working with in the CCM program can
- Assess your symptoms,
- figure out the level of care you need,
- provide instructions on how to manage the care at home if that’s safe,
- Schedule a new appointment if the problem is not an emergency, but needs urgent care
- reach out to the physician on call
Care Coordination
While the CCM team is able to offer some assistance, if an acute problem arises, urgent care services may be needed. Your care team will help to access the appropriate level of care.
Real-life impact:
Linda started feeling dizzy and nauseous after taking her blood pressure medicine. It was Saturday at 11 PM. Linda didn’t panic and stayed calm, unlike most people. Rather than waiting for her doctor’s office to open on Monday, she called her CCM hotline. Linda’s nurse went over her medications, realized she’d taken a double dose, told her to skip her morning dose, and made an appointment for a check-in the next day. No ER visit needed, and her problem was solved.
8. Giving Fully Customized Care
Taking Care of Patients: Mix and Match.
Everyone is a different patient with different:
Clinical objectives and goals
Care culture and belief systems
Funds and monetary control
Family systems and support
Life configuration and hurdles
Comprehensive Care Management addresses this with tailored and thoughtful individualized care.
Components of Personalized Care
Medical Management
Profiling each chronic condition
Developing a customized medication schedule
Monitoring certain aspects
Custom-designed intervention plans
Lifestyle Interventions
Nutrition guidance should be personal choice and compatible with culture.
Different forms of exercise are suitable for individual abilities.
Stress coping frameworks
Better sleep approach
Life Goals Integration
Thinking towards individual goals to accomplish.
Activities that the individual highly values the most.
Planning events like travel while factoring in health.
Value-adding occupation or leisure pursuits.
Support System Optimization
Educating and engaging family members.
Tying to the surrounding community resources.
Available financial aid resources.
Providing transport arrangements.
Continuous Adaptation
Your care plan evolves as your goals change.
Your health status shifts.
New life events occur.
New treatments become available.
Personalization in Action
- David was more focused than just managing COPD: in 8 months, he was to walk his daughter down the aisle. Hence, the CCM constructed an individual care plan built around a goal: pulmonary rehab, stratified walking programmes, timed medication, a plan for emergencies, and altitude adjustments for the destination wedding. He was able to walk down the aisle and didn’t need supplemental oxygen.
9. Improves Quality of Life More than Anything Else
Beyond the Numbers
Sure, we look at A1C and blood pressure, but ultimately what matters most to patients is simply feeling better and living life to the fullest.
Quality of Life Improvements
Physical Wellbeing:
- More energy during the day
- Better, deeper sleep
- Less pain and discomfort
- More improvement of stamina
- Fewer symptoms that debilitate the individual
Emotional Health:
- Less anxiety about one’s health
- Decreased illnes-related depression
- A feeling of more control
- Better self-esteem
- Improved ability to manage stress
Social Engagement:
- Attending family gatherings
- Keeping friendships
- Participating in hobbies and interests
- Traveling confidently
- Going to important events
Functional Independence:
- Continuing to work or volunteer
- Keeping up with household chores
- Driving and running errands
- Staying independent with self-care
- Living in your own home
Financial Relief:
- Fewer missed work days
- Less out of pocket medical expenses
- Lower emergency copay costs
- Fewer trips and expenses to medical facilities
- Avoiding high cost medical bills
Patient Testimonials
“Before CCM, I was terrified to travel. Now I visit my grandchildren across the country because I know my care team is always available if I need them.” – Susan, 68
“I haven’t missed a day of work in 18 months since starting CCM. Before that, I was out constantly for medical appointments and sick days.” – Michael, 54
10. Generates Significant Cost Efficiency
The ROI Reality:
While CCM has costs, it creates far greater savings through prevention and early intervention.
Where Savings Come From:
Avoided Emergency Care:
- Average ER visit: $1,500-$3,000
- Prevented ER visits per patient/year: 2-3
- Annual savings: $3,000-$9,000
Prevented Hospitalizations:
- Average hospital admission: $12,000-$15,000
- 20% reduction in admissions
- Massive cost avoidance for high-risk patients
Complication Prevention:
- Diabetic complications: $50,000-$100,000+
- Cardiovascular events: $20,000-$100,000
- Early intervention costs: $1,000-$5,000
- Net savings: $15,000-$95,000
Optimized Medication Use:
- Prevents expensive drug interactions
- Ensures effective medication use
- Accesses patient assistance programs
- Reduces waste from discontinued medications
Productivity Gains:
- Fewer missed work days
- Better job performance
- Reduced disability claims
- Lower employer healthcare costs
The Numbers:
Healthcare System ROI:
- For every $1 spent on CCM, systems save $2-$4
- Medicare saves $1,200-$3,000 per patient annually
- 10-15% reduction in total cost of care
Patient Savings:
- CCM copay: $0-$30/month ($0-$360/year)
- Avoided ER copays: $100-$500 per visit
- Avoided hospital deductibles: $1,000+
- Net patient savings: $1,000-$5,000+ annually
CCM Success: What the Research Proves
Clinical Outcomes
Published Research Demonstrates:
📊 20% reduction in hospital admissions
📊 13% decrease in emergency department visits
📊 1-2 point drop in average A1C for diabetics
📊 10-15 mmHg reduction in blood pressure
📊 30-40% improvement in medication adherence
📊 25% fewer heart failure readmissions
Patient Satisfaction
Survey Results Show:
⭐ 85-90% of participants report high satisfaction
⭐ 92% would recommend CCM to others
⭐ 88% feel more confident managing their health
⭐ 76% report better quality of life
⭐ 82% feel better connected to their healthcare team
Healthcare Provider Perspectives
A comprehensive study of 71 healthcare professionals revealed consistent findings:
✓ Decreased hospitalizations
✓ Reduced emergency department utilization
✓ Improved patient engagement
✓ Better care coordination
✓ Enhanced quality metrics
✓ Higher provider satisfaction
Who Benefits Most from CCM?
Ideal Candidates
You’re an excellent candidate for CCM if you have:
✓ Two or more chronic conditions expected to last 12+ months
✓ Multiple medications requiring careful management
✓ Recent hospitalizations or frequent ER visits
✓ Several specialists requiring coordination
✓ Difficulty managing your conditions independently
✓ Complex health needs beyond routine primary care
Common Conditions Managed
Cardiovascular:
- Heart failure
- Coronary artery disease
- Hypertension
- Arrhythmias
Metabolic:
- Type 1 and Type 2 diabetes
- Obesity
- High cholesterol
- Metabolic syndrome
Respiratory:
- COPD
- Chronic asthma
- Pulmonary fibrosis
Renal:
- Chronic kidney disease
- End-stage renal disease
Mental Health:
- Depression
- Anxiety disorders
- Bipolar disorder
- PTSD
Neurological:
- Dementia
- Parkinson’s disease
- Multiple sclerosis
- Epilepsy
Other:
- Arthritis
- Autoimmune diseases
- Chronic pain
- Cancer survivors
For Healthcare Providers: Proper billing for CCM services requires understanding CPT codes, including office visit codes 99211, 99213, the complete 99211-99215 series, and new patient codes 99202-99205.
The Essential Elements of Effective CCM
- Dedicated Care Coordinator
You have a Primary contact who knows your entire health history. They manage the different pieces of your care and help you navigate the healthcare system. - Comprehensive Care Plan
An exhaustive and individualized care plan that includes all of your health problems as well as conditions, medication, care objectives, and needs that is updated frequently to reflect your current status. - Regular Contact Schedule
There has to be a minimum of clinical contact of 20 minutes every month. More frequently if the patient has complex problems or is clinically unstable. - Advanced Technology
Secure messaging and telehealth, remote patient monitoring, and other integrated electronic health record technologies. - Multidisciplinary Team
A seamless collaboration of health care professionals and support personnel, e.g. physicians, nurses, care coordinators, pharmacists, social workers, and other specialists. - Patient and Caregiver Education
You and your family are educated to a level of empowerment that provides the knowledge, skills, and confidence to engage in self-management. - Community Resource Connections
You are connected with support groups, social services, home care services, and other community resources.
Transform Your Chronic Disease Management Today
Living with a chronic disease is challenging enough. Your healthcare shouldn’t make it harder.
Chronic Care Management offers the proactive, coordinated, comprehensive support you need to not just manage your conditions, but to thrive despite them.
Take the Next Step
🔗 Explore Our Chronic Care Management Services
Discover how coordinated, proactive care can transform your health outcomes and quality of life.