What Does a Chronic Care Management Nurse Do?
Medicare’s Chronic Care Management (CCM) program supports patients in managing multiple chronic conditions, slowing disease progression, preventing costly care, and enhancing quality of life. Nurses play a crucial role in this program, particularly for high-risk, vulnerable populations.
The Institute of Medicine affirms the expanding role of nursing in CCM, stating in a report, “Nurses are being called upon to fill primary care roles and to help patients manage chronic illnesses, thereby preventing acute care episodes and disease progression.”
Nurse care managers serve as a bridge between physicians and patients, providing essential support, education, and coordination between visits.
According to the American Academy of Ambulatory Care Nursing (AAACN), nurses in CCM go beyond routine patient care, achieving a deeper level of engagement that helps patients effectively manage conditions like diabetes, hypertension, and heart failure. Research indicates that engaging nurses in chronic care reduces hospitalizations and improves healthcare navigation, ultimately leading to better outcomes.
Chronic Care Management staff requirements
Guided and monitored by practitioners, care managers serve as the point of contact between the patient and practice and are essential to the program’s success.
The Centers for Medicare & Medicaid Services (CMS) require that the billing practitioner must be a physician or non-physician resource, including:
- Certified nurse midwives (CNMs)
- Clinical nurse specialists (CNSs)
- Nurse practitioners (NPs)
- Physician assistants (PAs)
While the billing practitioner must be involved in activities such as oversight, management, collaboration, and reassessment, the following clinical staff can support the billing practitioner under general supervision, including:
- Registered nurses (RN)
- Licensed practical nurses (LPN)
- Certified nursing assistants (CNA)
- Health coaches (in some areas)
RNs may perform independent chronic care visits, providing a host of CCM services based on the supervising physician’s orders. The nurse care manager’s skills and role enable reimbursable services, maximize care team value, reduce physician burnout, and enhance outcomes for patients with one or more chronic illnesses.
Roles and responsibilities nurses hold in Chronic Care Management
It’s not unusual for a nurse care manager to connect with up to 250 patients per month. Often, they are the care team member who interacts most with patients, executing nearly all of the program services that patients expect.
Most of a nurse care manager’s day is spent on the phone with patients, discussing their chronic conditions, managing goals with care plans, and getting to know the patient. As part of remote medical care, ongoing and direct patient contact is vital to program success.
Remote medical care and monthly patient calls
In an interview with ThoroughCare, a nurse care manager, Marie, shared her monthly routine. On average, she reaches out to 170 patients via phone calls for at least 20 minutes per patient.
Nurse care managers focus on several areas core to CCM’s purpose, including:
- Answering patients’ medical questions
- Medication management and reconciliation
- Conducting assessments like health risk or social needs evaluations
- Care planning and goal-setting
- Care coordination and care navigation support
- Encouraging preventive care
- Providing patient education and self-management coaching
Ultimately, nurse care managers collaborate with patients and their physicians to:
- Effectively manage chronic conditions
- Reduce the risk of disease-related complications
- Avoid exacerbations and the need for high-acuity care
Care planning is a core part of a care manager’s duties.
A patient-centered care plan typically includes treatment options, medications, and follow-up appointments. It should outline a patient’s health priorities and goals with an action plan to identify barriers. It also covers how the nurse and patient will work together toward achieving SMART goals.
Nurse care manager administrative duties
In addition to preparatory work before patient calls and the monthly CCM calls, nurse care managers have administrative duties to ensure that the program meets Medicare billing requirements. They are responsible for documenting any updates, physician orders, or patient commitments.
They also may use their monthly CCM time to coordinate with other providers inside or outside the organization, facilitate community or social referrals, and generate analytics reports on progress.
Additional opportunities for nurse care managers
CCM nurses can also be valuable partners in other Medicare care management programs, such as Transitional Care Management, Annual Wellness Visits, and Advance Care Planning.
Transitional Care Management (TCM): This 30-day service oversees and facilitates a patient’s transition from one care setting to another, such as from a hospital to their home. TCM aims to ensure patients receive continuous care and avoid gaps in service and readmission.
A physician or qualified non-physician practitioner, such as physician assistants, nurse practitioners, or clinical nurse specialists, can deliver and bill for TCM services. Nurses can perform TCM services under a physician's supervision. Explicitly, they can provide the non-face-to-face aspects of TCM care coordination while the physician oversees the overall management and performs any necessary face-to-face visits. This is considered general supervision according to Medicare guidelines and state practice laws.
Annual Wellness Visits (AWV): This yearly assessment evaluates a patient's current health status, including their physical and mental well-being, for the purpose of preventive health planning. The AWV provides an opportunity to discuss needed screenings and vaccinations, as well as address any care gaps.
A physician or qualified non-physician practitioner can complete and bill for the AWV, including physician assistants, nurse practitioners, or certified clinical nurse specialists. A registered nurse can perform this service under the direct supervision of a physician.
Advance Care Planning (ACP): In addition to physicians and physician assistants, ACP can be delivered and billed by non-physicians legally authorized and qualified to provide it in the state where the services are provided. These roles include NPs and CNSs.
Other nursing roles can participate in ACP services under a physician’s supervision. They can help educate patients, facilitate communication with family members, and provide needed documentation.
Essential skills for Chronic Care Management nurses
In addition to the invaluable role that nurse care managers play, the most successful in the position are highly skilled in essential capabilities, including:
- Relationship building with patients
- Serving as patient advocates
- Motivational interviewing
- Building internal relationships within the practice
- Networking with community and social support organizations
- Organizational skills
- Communicating with patients and families
- Collaborating with other professionals
- Navigating the broader healthcare system
Traits like persistence, empathy, organization, and reliability complement a nurse’s broad medical knowledge and experience, making them invaluable in CCM roles.
ThoroughCare gives nurses the tools to deliver Chronic Care Management
Nurse care managers are empowered and equipped to oversee and deliver care management programs with ThoroughCare. As a comprehensive software platform, ThoroughCare streamlines care management across all program types by automatically accounting for Medicare’s rules and requirements while documenting service records.
Our end-to-end workflow simplifies billing for Chronic Care Management, providing a consistent, evidence-based approach while enabling flexibility to meet individual patient needs.
Key questions answered
What role do nurses play in Chronic Care Management?
Nurse care managers act as a bridge between physicians and patients, providing critical medical support, education, coaching, and care coordination between in-person visits. Nurses are uniquely qualified and educated to function as chronic care managers, especially for high-risk and vulnerable patient populations.
Within the Chronic Care Management programs, nurses in advanced practice roles, like nurse practitioners (NPs) or clinical nurse specialists (CNSs), can directly deliver and bill for CCM and other care management services. Registered nurses, licensed practical nurses, and certified nursing assistants can support CCM services when supervised by a physician.
In these capacities, nurses provide remote medical care, conduct monthly patient calls, coordinate care, and educate and coach patients on self-management. Most importantly, they guide care planning efforts by documenting patients' symptoms and chronic conditions with personalized health assessments, goals, and commitments.
What skills and experience do Chronic Care Management nurses need?
CCM nurses need broad medical knowledge and direct care experience, particularly with high-risk patients with chronic conditions. Through hard and soft skills like time management, empathy, persistence, and building a goal-oriented, patient-centered relationship, nurse care managers are instrumental in supporting physician orders, improving outcomes, and enhancing patient quality of care.