CCM is an essential part of primary care that involves non-face-to-face coordination services done outside the regular office visit. It is meant for patients with two or more chronic conditions, expected to last at least 12 months or until the patient's death, that place the patient at a significant risk of death, acute exacerbation/decompensation, or functional decline. We also provide Principal Care Management (PCM) for individuals with a single, high-risk condition.
An estimated 117 million adults have one or more chronic health conditions, and one in four adults have two or more chronic health conditions (CDC 2021).Individuals with multiple (>2) chronic conditions (MCC) present many challenges to the health care system, such as effective coordination of care and cost containment. These individuals incur over 90% of all Medicare spending while frequently having care fragmentation (CMS 2023).
CMS recognizes Chronic Care Management (CCM) is a critical primary care service that contributes to better patient health and care (CMS, 2021