Chronic Care Management: What It Is and How to Deliver It

Chronic care can be delivered in six ways. These six specific areas that can be applied in chronic health conditions, clinical settings, and patient populations will be explored in this blog post.

Chronic Care Management: What It Is and How to Deliver It

Chronic care management refers to a comprehensive approach to care designed to keep patients actively engaged in and aware of the care they receive. Attention is given to the physical, emotional, and social aspects of the patient’s care.

Regardless of if patients are insured or uninsured, or if they are being treated in a live-in skilled nursing facility or a community-based setting, they may need help with their chronic care management. When a patient is actively involved in their chronic care management, they will be more likely to feel engaged, empowered, and committed to their overall health and wellness.

How Can You Support Patients in Their Chronic Care Management?

1 – Improved Support for Patients’ Self-Management

Patients who are empowered to manage their chronic care are better able to self-manage their conditions. They will be able to effectively communicate their needs and present their needs to their health team and caretakers.

2 – Well-Designed Care Delivery

Patients will also have an opportunity to have an active role in the presentation of their care. They will be able to voice their opinions, needs, and desires regarding their care. They will be more informed about their medical conditions and the treatments they are receiving.

3 – Access to Expertise and Decision Support

Patients will be able to get more access to expertise and decision support. Care and treatments that are delivered to patients will be evaluated based on their best interests and individualized needs. Instead of patients receiving care based on standards, best practices, and performance measures, they will be able to receive care that is appropriate for the individual.

4 – Community Support

Patients will be able to receive support in their chronic care management from their community members. They will be able to form connections with others and learn how they can support each other.

5 – Availability of Clinical Information

Patients will also be able to be more readily informed of the clinical information regarding their chronic health conditions. They will be able to access and read the important clinical literature that is available on their condition.

6 – Well-Organized Systems and Provider Roles

A well-designed, well-organized system and provider roles will be put in place to support patients with their chronic care management. Instead of having multiple caretakers to know about their conditions in different settings, patients will have an easier time communicating all of their information to one caretaker who will be able to coordinate their care.


When you provide your patients with the support they need and deserve, they will be more empowered in their care. Chronic care management can be provided in a variety of settings and populations.

Patients and families will be able to receive support with their chronic care management needs. They will be able to continue to live their lives as they are supposed to.

Should you be in search of the best care management solutions, come to Medistics Health. Whether your patient has chronic conditions, behavioral health conditions, or just needs help transitioning out of an inpatient facility, Medistics is there to simplify their experience.

Profit Calculator Assumptions: 40% of total Medicare patients enrolling is based on (i) Medicare Chart Book’s data showing that ~68% of medicare patients qualify for CCM (2 or more chronic conditions), and (ii) that ~40% of eligible patients will enroll.

For typical providers, $46.67 of net profit per patient per month is based on a Medicare reimbursement per patient per month (national average) for various care management CPT codes.

CPT and other codes, descriptions and other data are copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).