How CCM Can Prevent Chronic Conditions from Escalating

CCM is about putting the patient front and center, helping to prevent health issues from escalating, and truly making a difference in the new value-based care environment.

By Lisa R. Esch, Chief Population Health Innovation Officer

In the patient-centric world we’re moving toward, every stakeholder is looking for a direct line to the patient. Insurance and pharmaceutical companies, in addition to providers, all want to reach the patient, and each one with their own intents and purposes. When it comes to patients dealing with chronic illnesses of five or six different comorbidities, there could be that number of physicians’ offices reaching out to those individuals. This sort of communication is often one-sided, with the patient given no information about how to get a hold of someone when they actually need them most.

With so many people wanting time with the patient, it’s vital that any new engagement provides value and offers an open line of communication in return. CMS’s new program, Chronic Care Management (CCM), created to assist this aging population, makes it possible to build a trusted relationship with the patient to help them navigate the whole healthcare system through one direct source – very often the care coordinator.

Dedicated Contact

The combination of evolving technology and the move to value-based care has had a significant effect on the way providers and patients communicate, requiring them to adjust to new ways of interacting within the healthcare system – all with of the objective of avoiding rehospitalization.

For very sick patients with multiple chronic conditions who are constantly in and out of physicians’ offices or dealing with other types of care, an additional layer may be perceived as burdensome and there may be resistance to a CCM initiative. On the other hand, there is a segment of the patient population that isn’t receiving as much attention as perhaps they should. Those patients, most of whom are 65 years of age or older, may been dealing with several conditions, but aren’t necessarily high users of the system … yet. These are the patients who may benefit most from having a care coordinator coach them and work with them to manage the complexities of the healthcare system.

Eliminating Obstacles

Unfortunately, the healthcare system still isn’t patient-centric and at this time these mid-level patients become lost trying to navigate it. Indeed, studies show that this population all too often goes under the healthcare radar. Only 8% of Medicare patients interact with their doctors weekly and more than 60% of patients with chronic conditions visit their physicians infrequently or rarely.

By working with this segment of the patient population, while their conditions aren’t severely impacting their lives, care coordinators can: remove the complex layers involved in navigating a healthcare organization; directly address their needs to prevent their health from worsening; advise them to stay active; and keep them out of hospital before they become higher-risk patients.

Staying Healthy

If we step back and think about the patient and their journey as they navigate the delivery of care in the new value-based model, it helps to prioritize what the patient and their care providers need to be focused on. Good care coordination should be about determining how best to engage those patients to help them stay healthy, active and ahead of any unforeseen healthcare episodes.

Take Allen, for example, an 80-year-old widower, recently remarried to a 65-year-old woman and dealing with several chronic conditions. While many may automatically imagine his life as sedentary, he and his new wife live quite a full life of daily power walks, running around after grandchildren and international travel.  He, like many his age, continues to lead a vibrant life, and doesn’t want it to be disturbed by unplanned medical incidents, such as ending up in the ER. Through working with a care coordinator with whom he has built a trusted relationship from weekly communications, he is able to be proactive about managing his conditions. Together he and his care coordinator address health issues before they become serious, ensuring he stays active and helping him to recognize symptoms before they escalate.

“This kind of service and having a direct contact to communicate with quickly and easily, can actually be a lifesaver in some cases, something that many people genuinely need.” – Allen, the patient.

By putting the patient at the center, care coordination through CCM provides a personable connection to the often difficult healthcare journey. Frequent interactions turn into engaging relationships based on positive reinforcement of care. CCM changes the playing field of communicating with the patient to make this interaction helpful, rather than disruptive.

Related Information:

What’s Holding Large Practices Back from Committing to CCM?


  1. Hi Lisa, healthcare information is very beneficial for every people. When I want to take care of my health & my family, then I have to do research on blog, read more information which is very important. After reading you post I can say that this is important for me and everyone.



  1. […] How CCM Can Prevent Chronic Conditions from Escalating […]


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