How Does Chronic Care Management (CCM) Improve Outcomes and Reduce Costs?

The cost of care for most chronic disease is quite high. Unmanaged diabetes, heart disease, and various other conditions often result in many expensive interventions, hospitalizations and poor outcomes. Many unmanaged chronic conditions lead to more emergency room (ED) visits, hospital admissions, more severe illness/co-morbidities and death.  


Chronic Care Management, or CCM, is the coordination of care services, which are furnished outside of regular office visits. The target population is patients with two or more chronic conditions that are expected to last twelve months or longer, or until the patient’s death. These conditions often place the patient at significant risk of death or functional decline, increase the likelihood of multiple hospitalizations, and involve a high level of medical care and follow-up. Certain behaviors on the patient’s part, however, may lead to an enhanced quality of life or a delayed reduction in decline.


Providers use Chronic Care Management (CCM) to improve chronic patient care. CCMs add a constant line of communication with patients outside the office allowing providers to monitor their health more closely (and continuously). These programs help providers reduce costs and improve patient outcomes associated with chronic disease.   


Better managed chronic disease, reduces the costs of care, improves the health outcomes of patients and their health status – while increasing efficiency of care, reducing costs of the system, increasing patient satisfaction and improving health outcomes.  Each component of the CCM program results in a reduction in costs and improvement in quality of care and positive health outcomes.  


Three key components of Medsien’s CCM – eligibility, enrollment and engagement – together increase patient engagement and patient satisfaction, which in turn improve health outcomes and reduce costs. But how specifically do they do this?  


Eligibility is identified electronically using Medsien’s sophisticated software and the EHR; then CCM dedicated staff (CMAs) provide direct outreach to enroll identified high-risk patients. This increases the number of eligible patients in the CCM program, leading to more patients, getting better, more managed and targeted care. 


Dedicated medical staff then engage enrolled patients and provide and manage consistent, personalized, ongoing care, which increases patient engagement, personalization of care, patient satisfaction and the quality of care – all of which yield improved health outcomes. A designated CMA team member connects with each patient regularly to support and better educate patients on lifestyle modifications, medication adherence and health status monitoring in management of their chronic disease(s). During these regularly scheduled check ins, patients receive consistent, continuous and coordinated care. Regular, consistent monitoring, health education and support, as well as highly coordinated care across interventions and concerns improve health status, reduce severity of disease and improve health outcomes. Improved health outcomes reduce the high costs of unmanaged chronic disease — decreased ED visits, hospitalizations and other medical interventions.   


Direct, personalized, and ongoing outreach to patients – along with coordination of their care across all care teams – on behalf of the practice, increases health and patient education, increases coordination of care, leading to increase in patient satisfaction, and improved health outcomes – and reduced severity of illness and death.  Improvements in health outcomes, also reduce the costly ED visits, costly interventions and hospitalizations — further reducing the costs of care associated with most severe, unmanaged chronic conditions.  


Medsien Chronic Care Management (CCM) is meaningful care for your patients – anywhere.  Medsien provides a comprehensive clinical monitoring platform that can enable the rapid implementation of successful remote care solutions for your practice. Medsien provides a unique hybrid software and staffing model; scalable implementation of valuable remote services to your patients – all with no upfront investment or administrative burden.   


To read more about the benefits and impact of CCMs:

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