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How to successfully outsource chronic care management at a small practice


Successfully implementing a CCM program starts with laying the operational groundwork.

A great deal has changed in healthcare delivery since 2015 when CMS began to formally recognize the importance of Chronic Care Management (CCM) and reimburse it under its own distinct billing codes. Health technology has made remarkable advancements, the size of the senior population continues to grow tremendously, and the global pandemic has resulted in years of digital transformation taking place in a matter of months. These advancements couldn’t have come soon enough, as 6 in 10 adults have at least one chronic condition today, accounting for 90% of U.S. health expenditures annually.

Still, many small physician practices are hesitant to work with third-party organizations to implement formal CCM or remote patient monitoring (RPM) programs. Many are apprehensive about opening sensitive patient medical charts to a third party, and others are concerned about the operational challenge of managing a remote staff that they neither hired nor trained. Further, physicians may also be wary of allowing remote care managers to contact patients they’ve never personally met and unsure how patients will react to this change.

While all of these are valid concerns, there is a strong argument to be made that the benefits of implementing CCM programs far outweigh any potential onboarding or integration snags. Incorporating a dedicated CCM program can provide many operational and financial benefits to practices regardless of size, thus improving outcomes for patients overall.


Successfully implementing a CCM program starts with laying the operational groundwork: integrating new staff and installing healthIT software. Committing time and resources into integrating remote care managers early on is critical to reaping the benefits long term. By treating remote care coordinators as true extensions of your staff, adapting to the culture, tone, and workflow of your practice, they eventually become integral parts of practice operations, and in some cases, may even be willing to work in the office a few days a week to get additional face-to-face time with practice staff and patients. This frees up existing staff to manage other important tasks.

Another element critical to a successful CCM program is ensuring seamless integration or cooperation with your practice’s existing EHR software. Adding another health IT system into your practice is not always easy, but given that staff members spend 90% of their day in our EMR, finding integrated EHR and CCM solutions can save a great deal of time, money, and resources.


After explaining the role of care coordinators and getting patients to answer that initial call from an unfamiliar number, the connection between patients and care coordinators can become a lifeline for many. Whether they are supporting medication adherence by reminding patients to fill prescriptions, following up on issues addressed during in-office visits, or providing mental health check-ins, care managers can fill important gaps between in-office visits. After following up with the same patients each week or month, these remote coordinators often build as strong of relationships with patients as we do as providers.

Additionally, with the help of connected RPM technology, care managers are able to stay even more closely connected to high-risk patients, remotely collecting analytics such as a patient’s blood pressure, oxygen and glucose levels, or even sleep quality, then relay that information to the provider. Using these real-time analytics to inform a patient’s care can have a dramatic impact on outcomes and increase patient satisfaction.

Supporting the Practice:

With a CCM program, practices can put themselves in a stronger financial position by earning revenue for the services many are already providing, such as primarily patient phone calls. Today, over 80% of patient communication is over the phone, with even small family practices averaging between 1500-1600 calls per week.

Without CCM, these calls can represent an immense burden for a small administrative staff, as well as a missed source of revenue from these billable actions. By implementing a formal CCM program and enlisting the support of trained care coordinators, burdensome administrative calls become opportunities for substantive care management, with coordinators collecting additional health information on the practice’s behalf and inputting it directly into the patient’s record for the physicians to view.

During the pandemic, CCM became a lifeline for many practices like mine, helping to fill gaps in care while our staff dealt with other issues related to COVID-19. Even as we emerge from the pandemic and into healthcare’s evolving business and regulatory environment, CCM can enable even the smallest of practices to not only breakeven but come out ahead, all while improving overall patient care.

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