Chronic Care Management: A Care Coordinator Working for You Between Visits

What Chronic Care Management Is

Chronic Care Management (CCM) is a Medicare service for people with two or more chronic conditions expected to last at least a year. At Hope Integrative Medicine, it means a care coordinator who works with your provider between visits: checking in on how you are doing, following up on results, handling paperwork and keeping your care plan current, so your care keeps moving instead of waiting for the next appointment.

"I Already Get This"

Many patients tell us they already get this from their doctor. Your provider does care about you between visits. The difference is time: in care built around office visits, your provider catches up on your chart before the visit, sees you, ties up loose ends afterward and may not look at your case again until your next visit.

Chronic Care Management adds three things office visits alone do not:

• An assigned care coordinator. One team member who knows your case, works closely with your provider and tracks, revisits and charts your progress toward your goals every month.
• Access between visits. Enrolled patients can reach the care coordination team through secure text messaging, and your coordinator touches base with you between appointments.
• A care team that acts before the next visit. Your coordinator checks on results and starts the next step, follows up after a new medicine and tells your provider when something may warrant changing the plan.

Office Visits Only, or Care Between Visits Too

The same patient, two ways: care built around office visits, and care with Chronic Care Management

Moment	Office visits only	With Chronic Care Management
Before your visit	Your provider reviews your chart to catch up on what is going on, what is still outstanding and any new results.	Your provider still reviews your chart, and your care coordinator has kept open items moving since your last visit.
At your visit	Your provider asks how you are doing, may examine you, and talks through where things stand and the plan.	The same visit, and a care coordinator may also see you in the office.
After you leave	Your provider ties up loose ends, writes orders and documents the visit, and may not look at your case again until your next visit.	Your care coordinator reviews what happened at the visit: what changed, how you are doing against your goals and the trends in any new data.
You start a new medicine	You wait for your next visit to say how it is going.	Your care coordinator checks in to see how it is going and tells your provider if anything comes up that may warrant changing the plan.
You are working on a goal, like weight or blood pressure	Progress gets discussed at the next visit.	Your care coordinator touches base between visits and asks about your blood pressure or blood sugar readings.
A result comes back	It is reviewed, and the next step may wait until your next visit.	Your care coordinator checks on it and starts the next step instead of waiting for the next visit.
Paperwork	Prior authorizations, referrals and renewals are handled as part of your provider's follow-up work.	Your care coordinator handles prior authorizations and requests referrals and renewals.
Labs before a follow-up	You keep track of the lab order and the lab visit yourself.	Your care coordinator makes sure you have your lab order, that you went, and that results are back in time for your follow-up.
Your other providers	Each may see only part of the picture.	Your care plan is kept up to date and shared, so everyone works from the same plan.

One Patient, Two Ways

Picture a patient with diabetes and high blood pressure, working on her weight. This is an illustration, not a real patient.

With office visits only, she sees her provider, they agree to start a new medicine and order labs, and she leaves with a plan. Over the next three months she wonders whether a side effect matters, misplaces the lab order and goes back to her follow-up without results. The visit is spent catching up.

With Chronic Care Management, her care coordinator reviews the visit afterward and adds the new goals to her care plan. Between visits, the coordinator checks in on the new medicine, asks about her blood pressure readings and passes a concern to her provider, who adjusts the plan. The coordinator makes sure she has her lab order, confirms she went and sees that the results are back in time for the follow-up. That visit is spent on what comes next.

What Your Care Coordinator Does Behind the Scenes

Much of this work is invisible to you, which is the point: it keeps your care moving between visits.

• Handles prior authorizations.
• Checks on results and starts the next step instead of waiting for your next visit.
• Requests referrals and renewals.
• Makes sure that when labs are ordered you have your lab order, you went to the lab of your choice, and the results are back in time for your follow-up.
• Keeps up with the big picture as your care evolves, updates your providers and your care plan, and shares the plan so everyone is working from the same sheet of music.
• Generates and tracks trends in your care over time, giving you and your providers a bird's-eye view of your progress, or your challenges.

Why the Program Makes This Possible

For years, the work that holds care together between visits was not paid for on its own. An evaluation prepared for Medicare explains that physicians historically were not paid separately for this work outside a face-to-face visit, and that primary care clinicians had long argued that visit-based payment undervalued what they and their teams do for patients between visits.

In January 2015, Medicare began paying separately for Chronic Care Management. In interviews for the same evaluation, providers and their staff said the new funding allowed them to expand the staff dedicated to care management.

That is what CCM does at Hope. Without the program, a team member dedicated to your care between visits would be cost-prohibitive. With it, your care team can be proactive instead of waiting for your next appointment.

What an Evaluation for Medicare Found

Mathematica Policy Research evaluated the first years of CCM for the Centers for Medicare & Medicaid Services (CMS). More than 684,000 Medicare patients received CCM in its first two years. The evaluation compared patients who began CCM in 2015 and 2016 with similar patients who did not, matched on demographics, health, frailty, past use of care, spending and geography.

• Over 12 months (273,225 CCM patients and 202,679 comparison patients), growth in hospital stays was lower by about 47 per 1,000 patients and growth in emergency department visits was lower by about 23 per 1,000 for CCM patients.
• Over the same 12 months, growth in Medicare spending was about $28 per patient per month lower, not counting the CCM fee. In the group followed for 18 months, spending growth was about $74 per patient per month lower, and growth in hospital stays and emergency department visits was lower by about 99 and 76 per 1,000 patients.
• CCM patients had about one more primary care visit over the year than the comparison group.
• In interviews, patients generally appreciated the monthly check-ins and described them as "reassuring" and "a good reminder." One said: "You're talking to the same person every time. It's somebody that knows my history, knows my medications, knows the doctors I'm seeing, knows what I'm being treated for."

What the Evaluation Cannot Tell You

It was an observational comparison, not a randomized trial. Clinicians chose whom to offer CCM, and patients chose to take part, so they may have been more ready to engage in their care. The authors note their savings estimates may be overstated, and the data come from 2015 and 2016 and from traditional fee-for-service Medicare only.

Results on spending were mixed. The 12- and 18-month analyses found slower spending growth, but in the first 6 months spending growth was about $14 per patient per month higher, not lower, and when patients who died during follow-up were left out, the 12-month spending difference was no longer present.

These findings describe groups of patients, not a promise for any one person. Seeing a licensed, experienced provider who knows you is essential: your provider reviews the evidence, risks and benefits in the context of your health and decides with you.

Who Benefits Most, and Who May Not Need It

Not every patient needs Chronic Care Management. The patients who benefit most live with several chronic conditions, and their care is often less than ideal without someone engaging with them between visits and carrying out the care plan toward the goals they have set.

Medicare's rules require two or more chronic conditions expected to last at least 12 months that put you at significant risk of death, a sudden flare-up or worsening, or a decline in how well you function day to day. CMS notes that practices may consider things like the number of illnesses, the number of medicines, or repeat hospital stays or emergency department visits when deciding who needs CCM.

If your conditions are stable and simple to manage, routine visits may be all you need. Eligibility is a clinical decision your provider makes with you.

Cost, Consent and Your Right to Stop

Medicare Part B may pay for CCM if you are eligible. After you meet the Part B deductible, you generally pay 20% of the Medicare-approved amount, and supplemental insurance such as a Medigap policy may help with your share. Medicare Advantage plans must cover what Original Medicare covers, but costs and rules vary by plan, and coverage under other plans varies too.

CCM starts with a visit with your provider and your consent. Before you agree, we explain the service and your possible cost-sharing. Medicare allows only one practice to provide CCM for you in a calendar month, so your care has one home base. You can stop at any time; stopping takes effect at the end of the calendar month.

Not an Emergency Service

Chronic Care Management is not an emergency service. In an emergency, call 911 or go to the nearest emergency room.

Read More

More on Chronic Care Management and primary care at Hope.

• Chronic Care Management: Care That Keeps Going Between Visits
• Adult Primary Care in West Ashley, Charleston

Sources: Medicare.gov, Chronic Care Management Services; CMS Medicare Learning Network, Chronic Care Management Services (MLN909188, June 2025); CMS, Chronic Care Management for Complex Conditions; Mathematica Policy Research for CMS, Evaluation of the Diffusion and Impact of the Chronic Care Management (CCM) Services: Final Report (2017); CMS fact sheet, Policy and payment changes to the Medicare Physician Fee Schedule for 2015 (October 2014).