Chronic Care Management | November 2021 | Clinical Corner

November 15, 2021

Chronic Care Management (CCM)

Chronic care management is care coordination services done outside of the regular office visit for patients 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. These services are typically non-face-to-face and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month. The Centers for Medicare & Medicaid Services (CMS) recognizes that CCM services are critical components of primary care that promote better health and reduce overall health care costs.

Diabetes, CHF, COPD and CAD are the most common diagnoses referred for CCM and patients with these conditions are typically referred after an acute care encounter (ED visit, Inpatient admission, or readmissions, SNF admission). However, as we transition to downside risk in our value-based care contracts (Medicare ACO and Medicare Advantage gainsharing contracts, Commercial plans), MPP is looking to engage patients in CCM before the acute care encounter occurs to reduce avoidable utilization and healthcare costs.

Patients with newly diagnosed chronic illnesses are excellent candidates for referral to and enrollment in our CCM programs. Patients with stable but sub-optimal chronic conditions would benefit from earlier referral for education on self-management of their illness. Recently, MPP’s CCM program for COPD demonstrated a 20% reduction in readmissions and an overall decrease in healthcare expenditures. These results were highlighted as best practice by the Michigan Value Collaborative (MVC). Click here to view the MCV Case Study

CCM services include:

  • At-risk populations
  • Motivating patients to comply with necessary treatments
  • Care planning and goal development with patient
  • Care Manager assigned to patient performs regular “check-ins” with the patient
  • Focused on self-management of disease(s)
  • Tool kits (daily checklists, weight monitoring, diet coaching, medication reconciliation)
  • Discussion around disease progression and end-of-life options
  • Referrals to Palliative Care for symptom management


Benefits of CCM include:

  • Improved compliance with medication regimen
  • Alignment with PCP and care team
  • Decreased “avoidable” utilization
  • Earlier identification of signs and symptoms of exacerbation
  • Optimized quality of life


Referrals to CCM or any of our Care Management programs can be made one of three ways:


  1. Complete Referral Form located on the MPP Website


    • Completed Forms should be faxed to 810-800-7942


  2. Call: 844-368-1817


  3. Cerner Referral System (in Ambulatory EMR Only)





MPP is looking to increase provider and practice awareness of the Care Management programs available to you and your patients. For more information, please contact Andrea Phillips, Director of Care Coordination at or (248) 484-4947.