Quality & Clinical

Chronic Care Management

CCM offers ongoing preventative care to Medicare beneficiaries with multiple chronic conditions.

Chronic Care Management empowers patients through features like a dedicated care team, a 24/7 nurse line, and personalized support. Nurses and clinicians reach out each month to assist with care plans and goals tailored to individual patient needs. They can also help with appointment scheduling, medication refills, and directing patients to educational resources.

Outside of monthly checkpoints, CCM patients can also call the 24/7 nurse line with healthcare questions or concerns whenever they arise. If a patient has Social Determinant of Health needs, their nurse or care coordinator can direct them to local transportation services, food pantries, and support groups throughout Washington.

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Preferred Partner

ChartSpan, a leading Chronic Care Management (CCM) provider in the United States, currently serves more than 150 healthcare practices and systems nationwide. Their Chronic Care Management program has led to improved patient outcomes, including lower costs and reduced hospital readmissions, improved quality scores, and additional revenue* for practices.

On average, Medicare patients enrolled in ChartSpan CCM see a 52% reduction in 30-day hospital readmissions, when compared to patients who were eligible for CCM but didn’t enroll. ChartSpan customers also saved an average of $2,457 per year in total healthcare costs per enrolled CCM patient.

ChartSpan CCM clients receive complimentary Quality Improvement services to help raise their MIPS and ACO quality scores. CCM care coordinators can identify patient gaps in care, like missing vaccinations and screenings, and direct patients back to their provider—improving quality scores in the process.

Finally, ChartSpan’s CCM program can help practices earn reimbursements for the preventative care they provide. Practices can earn more than $100K in annual revenue with just 300 patients enrolled in a CCM program. Rural Health Clinics and Federally Qualified Health Centers can earn as much as $125K in reimbursements for CCM services.*

If you’d like to learn more, contact Caroline Kochelek at caroline.kochelek@chartspan.com to explore how ChartSpan’s CCM program can benefit your practice and your patients.

*Results may vary by provider.