Running a Chronic Care Management Program

What does it take to run a chronic care management program?

Running a chronic care management program takes a defined patient list, documented consent, a living electronic care plan for each patient, a monthly rhythm of outreach and coordination, named staff roles with supervision, and regular review of both care quality and records. Software holds these together, but the program design comes first.

A practice that starts with billing and works backward can end up with a time-logging exercise. One that starts with what patients need between visits builds a service, and the billing records follow from doing that work well.

Which patients should the program enroll first?

Enroll first the eligible patients the care team can help most with the capacity it has. Eligibility is set by Medicare; priority within the eligible group is a clinical and operational choice.

Under the CMS booklet MLN909188, a patient qualifies when they have at least two chronic conditions that are expected to last 12 months or longer, or until death, and that put them at significant risk of death, acute exacerbation or decompensation, or functional decline.

Build the candidate list from data, then let clinicians shape it. Query the EHR for patients with two or more qualifying conditions on the problem list, then add signals the care team cares about, such as recent emergency visits, hospital stays, many medications or gaps in follow-up. A clinician reviews the list and removes patients for whom CCM is not a good fit.

Size the first cohort to staffing, not to the size of the eligible list. Each enrolled patient needs real monthly contact, and a program that enrolls more patients than staff can reach produces missed months and thin documentation.

How should enrollment and consent work?

Enrollment should be a conversation in which the patient hears what the service is, what it may cost them and that they can stop at any time, followed by consent recorded in the chart before CCM work is billed. Written or verbal consent can both work if documented.

A good moment is a visit with the patient's own clinician, who can explain why the program fits them. Outreach calls from care managers also work when the script is clear and the patient can ask questions. Record who obtained consent, when, how and what the patient was told.

Track declines and revisit them. A patient who said no during a busy visit may say yes after a hospital stay. A structured decline reason helps the team see whether the problem is cost, confusion or a poor fit.

Plan for disenrollment as well. Patients move, change practices, enter hospice or simply decide to stop, and each case needs a recorded end date and reason so the patient leaves the monthly list and no further work is logged against them.

Building the comprehensive care plan

The comprehensive care plan is the working document of the program, not a form completed once at enrollment. The CMS booklet describes it as a patient-centered, electronic care plan based on a physical, mental, cognitive, psychosocial, functional and environmental assessment and an inventory of resources and supports.

CMS's CCM FAQs list typical elements, including a problem list, expected outcome and prognosis, measurable treatment goals, symptom management, planned interventions and medication management, while noting these are typical elements rather than strict requirements. Build the template around them, and let clinicians add what each patient needs.

• Goals in the patient's words: what the patient wants, such as staying out of hospital or walking to the shops, beside the clinical targets.
• Owners: who is responsible for each intervention, including outside specialists and community services.
• Review dates: when each goal and intervention is next checked, so monthly work has a clear agenda.
• Sharing: how the plan reaches the patient, caregivers and other clinicians, and when it was last shared.

A plan that never changes is a warning sign. If monthly contacts do not lead to updates, either the patient's needs are stable and the cadence can relax, or the contacts are not getting to the issues that matter.

What does a monthly CCM cadence look like?

A monthly cadence gives every enrolled patient planned contact early in the month, follow-up on anything that came up, coordination with other clinicians and a record check before month end. The rhythm should be predictable for staff and responsive for patients.

• 1. Start of month: generate each care manager's list, ordered by risk and by what is due in each care plan.
• 2. First contact: call or message each patient, review symptoms, medications and goals, and log what was discussed.
• 3. Follow-up: chase the actions from that contact, such as refill requests, specialist reports, appointments or community referrals.
• 4. Coordination: share relevant updates with the treating clinician and outside providers, and record who was contacted.
• 5. Mid-month check: identify patients with no contact yet and patients whose issues are still open.
• 6. Month end: confirm each patient's record shows the work done, the time spent by role and any care plan changes.

Events interrupt the cadence, and they should. A hospital discharge, an emergency visit or a new diagnosis moves a patient to the top of the list. Feed admission and discharge notifications into the work queue so care managers hear about them quickly.

Time and code rules sit on top of this cadence. Medicare's CCM codes include 99490, 99439, 99491, 99437, 99487 and 99489, which differ by who does the work and how much time it takes; the CCM billing guide covers them in detail.

Who does what on a CCM team?

A CCM team needs a billing practitioner who oversees the program, care managers who do most of the monthly work, and support staff who handle scheduling and records. Clear roles keep work from falling between people.

• Billing practitioner: the physician or qualified health professional who leads the patient's care, approves the care plan and is responsible for supervision.
• Care managers: nurses or other clinical staff who run monthly contacts, update the plan and coordinate with others.
• Pharmacist or clinical reviewer: medication reviews for patients with complex regimens, where the practice has this role.
• Coordinators: non-clinical staff for appointment booking, records requests and community resource referrals.
• Program lead: owns capacity, enrollment targets, quality review and the relationship with billing.

Write down what each role may do and what needs a clinician. Care managers should know exactly when to escalate a symptom, a medication question or a social need, and to whom.

Caseload limits matter more than headcount. Set a caseload per care manager based on patient complexity, and review it as the program grows.

Cover absences in advance. When a care manager is on leave, their patients still need monthly contact, so assign a named backup for each caseload and let the work queue move open tasks to the backup automatically.

How should the program review quality?

The program should review quality on two tracks: whether patients are getting the care the plan describes, and whether the records show it accurately. Both need a regular sample and clear owners.

For care quality, sample patients each month and ask whether contacts addressed the plan's goals, whether escalations happened when they should have, and whether outside clinicians received what they needed. Track simple measures such as the share of patients contacted each month and the time from a discharge notice to the first call.

For record quality, check that consent is on file, the care plan has been reviewed recently, time entries match the work described and the billing practitioner is correct. Findings go back to individual staff as coaching and to the program lead as process changes.

Patient feedback belongs in the review. A short question during monthly calls, such as whether the patient knows who to call, says a lot about whether the program is working.

A launch sequence for a new CCM program

This sequence orders the work so each step has what it needs from the one before.

• 1. Design: agree the program's goals, the billing practitioners involved, the roles and the escalation rules.
• 2. Patient list: build the eligible list from EHR data and have clinicians select the first cohort to match staffing.
• 3. Scripts and templates: write enrollment scripts, the consent record, the care plan template and contact note templates.
• 4. Work queues: set up monthly lists, event alerts for admissions and discharges, and month-end record checks.
• 5. Pilot: enroll a small cohort with one care manager, run two full months and fix what breaks.
• 6. Review: sample records and patient experience from the pilot, then adjust caseloads, templates and scripts.
• 7. Scale: add care managers and cohorts in steps, checking contact rates and record quality at each step.

How Agnotic can help

A CCM program depends on lists, plans and queues that stay accurate month after month. Agnotic Technologies builds care management software for clients: eligibility queries over EHR data, consent and enrollment records, electronic care plans with owners and review dates, monthly work queues with event alerts, and quality review tools.

Agnotic does not run CCM programs or employ care managers. It builds the software around the program the client's clinical team has designed, and integrates it with the EHR so the chart stays the record of care.

Sources

• CMS MLN909188: Chronic Care Management Services booklet (eligibility, care plan)
• CMS: Chronic Care Management frequently asked questions (typical care plan elements)
• CMS: Care management services under the Physician Fee Schedule