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Chronic Care Management: How to Avoid Common Pitfalls

June 30th, 2020 | 5 min. read



Content Team

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One of the biggest hurdles to implementing a Chronic Care Management (CCM) program at most practices is the fear of failure.

Practitioners fear they don’t have the staff or time to run such a program or they’re concerned about the rules and regulations.

All of these fears are valid but are not a reason to shy away from implementing a CCM program.


Well for one, the benefits of starting a CCM program are numerous. CCM programs are considered vital components of primary care, resulting in better health outcomes for patients while reducing overall healthcare costs.

But like any important implementation process, having a well thought out strategy can make the difference between success and failure.

We provide tips and best practices we’ve learned from other successful programs while simplifying the sometimes complex rules and regulations for them.

Our hope is to do the same for you.

In this article, we’ll walk you through some of the most common reasons CCM programs fail and give tips on how to avoid those all-too-common pitfalls.

Do You Have The Appropriate Staff Size?

You need to ensure you have the clinical staff available to manage a successful CCM program without overburdening your practice.

The Centers for Medicare and Medicaid (CMS) requires that a care manager for a CCM program be either a practitioner or one of the following certified resources:

  • Registered Nurse
  • Licensed Practical Nurse
  • Certified Medical Assistant
  • Health Coaches (in some areas)

Oftentimes these clinical staff will serve solely as a care manager for your CCM program. After all, workloads can be very demanding.

It’s not uncommon for a care manager to be managing 150 patients each month. With at least 20 minutes per patient, that adds up to at least 50 hours of time spent managing patients each month.

Whether you can shift one of your current clinical staff into a full-time role as a care manager or hire a new one, being prepared on the staff side will go a long way.

Regardless of which route you go, having a dedicated care manager is all but essential to your success.

Do You Have Enough Qualifying Patients?

This one may seem obvious, but it’s an important consideration that can often be overlooked.

You will want to ensure that not only do you have enough patients currently qualified to receive CCM care, but also enough influx of new qualifying patients that will sustain the program in the long term.

As a reminder, the Centers for Medicare and Medicaid Services (CMS) defines a qualifying patient as those with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

Rest assured, you most likely will not have a hard time finding enough qualified patients to sustain a successful CCM program.

CMS estimates that approximately one in four adults, including 70% of Medicare beneficiaries, have two or more chronic conditions, qualifying them to receive CCM.

Do You Have the Understanding On How To Run the Program?

One of the biggest hurdles for most practices to overcome when starting a CCM program is understanding how to run one.

We’ve helped hundreds of clients understand the ins and outs of CCM over the years. Luckily, not only is it not difficult, but it can be highly rewarding.

Being sure you understand what goes into the program, how to meet CMS requirements for care provision and billing, and the commitment it takes from you will set you up for success.

Do You Have a Care Management Software?

In other articles, we’ve covered the importance of good care management software in managing CMS programs effectively.

While your EHR can be a good starting point, these programs all have unique requirements that might be difficult (or impossible) to do in your EHR.

CCM is no different. Care management software can assist in:

  • Time Logging and Tracking
  • Creating a patient-centered care plan
  • Creating reports and program summaries to give to patients
  • Detailed dashboards and worklists to manage your program participants
  • Reviewing patient device data and triggering alerts

There are many software options for practices to choose from. In searching for the right platform, look to see that the software has features that address the bullet points above.

Do You Have A Plan for Success

Ultimately, you want to have a well thought out plan in place before starting your CCM program. The above tips should serve as a primer for any practice looking to get started.

You’ll also want to examine the financials of your practice, factoring in the additional costs and potential revenues that come with a CCM program. Cost factors to consider include:

  • Payroll expenses for new hires
  • Employee training costs
  • Care management software
  • Dedicated phone line(s) or phone system
  • Time cost associated with managing the program

These factors are not insurmountable, and CCM programs have shown they can be highly profitable revenue streams for practices.

ThoroughCare Makes It Easy To Run A Successful CCM Program

So as you can see, CCM programs fail because practices don’t ask the right questions. They don’t have a plan.

By asking yourself the questions we’ve covered above, you’ll ensure that you’re properly prepared to begin implementing your own CCM program.

If you want to go the extra mile, find that care management software that will help you!

ThoroughCare’s intuitive, clinician-friendly software equips providers with the tools needed to manage care coordination and wellness programs effectively.

ThoroughCare’s CCM solution features:

  • Your own secure, HIPAA-compliant software portal
  • Unlimited users and patients
  • Live Dashboard showing current CCM minutes
  • Guided interviews for CCM Care Plans
  • Task tracker (with timer) and Time Logging
  • Monthly Update interface for clinical staff and providers
  • Create Care Plan reports for the patient and other providers
  • Easily download summaries and upload them to your EHR
  • Integrates with Annual Wellness Visit Software
  • Easy Billing interface to easily submit CCM Claims 

Additionally, we have a dedicated support staff able to assist you throughout your journey, from program implementation to continuing management.

We strongly believe that we’re a team and will provide you with all the help you need along the way to success.

Furthermore, our software is constantly evolving based on feedback from our users. We actively listen to our customer’s needs and continually update the software to provide the best user experience.

We encourage you to explore all your options, but we’re confident that we can help you maximize revenues and provide the highest quality of care for your patients.