Chronic Care Management, what is it?

Chronic Care Management, what is it?

Well, the Centers for Medicare and Medicaid Services says that Chronic Care Management or CCM is the care coordination that is 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 or decompensation, or functional decline. It can be delivered to people with many different types of health conditions.

Chronic Care Management is actively being the patients advocate in the healthcare space. It is a team of individuals with gerontological working experience in, collaborating with older adults and their significant others to promote autonomy, wellness, optimal functioning, comfort, and quality of life from healthy aging to end of life. Gerontological nurses are the healthcare professionals consistently responsible for the 24-hour care of older adults across clinical settings. These are the individuals who have a long history of working in Skilled Nursing Homes, Hospice Care, Home Care experience, Case Management, Home Health, and other settings that work to serve the 65 years and older population.


Encouraging patients to use CCM will give them the support they need between visits. Having a regular touch point may help patients think about their health more and engage in their treatment plan, for example, by becoming more conscious of taking medications, managing fall risk, and other self-management tasks. Getting this help may also encourage patients to stay on track and improve adherence to their treatment plan. More frequent communication can also help make patients feel more connected to you and your staff.


CCM gives the Primary Care Provider an opportunity to deliver the coordinated care the patients need and deserve. Offering CCM can enable a Provider the ability to sustain and grow their practice and improve patient satisfaction.  Ongoing care management outside the in-person visit has not always been separately billable in payment, making it difficult for practices to sustain service provision. Offering care management activities CCM can provide you with additional resources to help your practice care for high risk, high needs patients.


It is well documented that the population of the United States and the world are aging. The number of older adults in the U.S. is steady rising and by 2030 this generation of people will double. In addition to the growing number of older adults, the oldest -old (including Centenarians) are increasing as well. These changing demographics and characteristics and the increasing recognition of disability and frailty across the aging spectrum will absolutely increase the need for quality care management. These older adults will have very different needs and preferences related to their care. A Gerontological nurse care manager is the perfect professional to ensure that the patient receives the level of care required to meet their individual needs.



 American Nurses Association. (2010). Gerontological Nursing: Scope and Standards of Practice(2nded.). Silver Spring, MD:


Connected Care Toolkit – Chronic Care Management Resources for Health Care Professionals and Communities (