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Chronic Care Management

Chronic conditions present a strong economic incentive for action

During the past century, a major shift occurred in the leading causes of death for all age groups, including older adults, from infectious diseases and acute illnesses to chronic diseases and degenerative illnesses. More than a quarter of all Americans and two out of every three adults have two or more chronic conditions, and treatment for this population accounts for 86% of the country’s health care budget.[1] Seven of the ten top causes of death are from the top nine chronic problems.

Nine of the top chronic conditions comprise 75% of the problems Medicare patients have. With 86% of healthcare costs going to treat chronically ill, this has become a major focus. With the aging of the US population, these chronic problems need to be managed to improve wellness and reduce the cost of care.

Medicare Chronic Care Management Opportunity

This program pays providers an average $43 (billing code 99490) per patient every month for non face-to-face care coordination and chronic care management. An average group can signup 500 patients generating an average revenue of $258,000 a year. Here are the requirements of the program:

  1. Patient has 2 or more chronic conditions for a year, must sign a consent and pay 20% co-insurance or $8.60 per month.
  2. Patient must have an office visit exam to start the program and documents a Care Plan.
  3. Provider must use a certified EHR to document problems, meds, allergies, and Care Plan with measurable treatment goals.
  4. Nurse or PA must spend 20 minutes per patient per month: contacting patient, coordinate care, reviewing medical history and documenting changes.
  5. Ensure patient has 24-hour-a-day, 7-day-a-week (24/7) access to care management services.
  6. Patient can not be in a nursing home, in-patient care, or other programs already paying for this patient and can only be paid to one provider per month.



Enablemyhealth CCM Solution

To ensure this program is profitable, an efficient process is required. Enablemyhealth is a patient care platform that allows physicians, nurses and staff to efficiently manage patient care and chronic care on a certified electronic health record and billing platform. Our Care Management module provides the following capabilities:

  • Simplifies the Chronic Care Management process by automatically generating one or more custom patient lists based on diagnosis and over 50 other criteria
  • Tracks the best time to call patients and uses that information to organize the call list.
  • Streamlines the updating of Care Plan, medications, problems and other clinical information without leaving the care list.
  • Uses advanced templates and speech recognition to customize the note and Care Plan to automatically pull clinical information from one visit to the next so it can be updated.
  • Logs patient calls and other tasks to make sure 20 minutes is spent each month and automatically adds the information to the note.
  • Automatically bills CCM visits with a selection of order set or pulling from prior months CCM encounter.
  • Exchanges clinical CDA data to send and receive patient data with other certified EHR.
  • Alerts providers via task email or texts and displays them on a provider dashboard to easily know which patient charts to review.
  • Inbound nurse management system routes calls to the on call nurses and eventually will take a message that is saved in the EHR and a text message is sent to alert someone to call the patient back.
  • Patient and physician portal allows patient clinical information and notes to be shared with the Care Team and family members. Secure messaging and file attachments are also supported.
  • Fax and call, text and email reminders are optional features.


CCM Work Flow

Enablemyhealth Chronic Care Module provides a 5 step process to document chronic care:

Chronic Care Management Processs

Chronic Care Management Processs

  1. Patient signs a consent form to join the Chronic Care program, which also specifies their preferred call times.
  2. Patient data is imported from CCDA clinical summary files or billing data or is entered into Enablemyhealth.
  3. A chronic care list is generated from the patient clinical data using a custom rules engine that displays the list based on the preferred call times.
  4. With one click the patient chart is opened and call tasks are entered to track the 20 minutes each month.
  5. Patient is called and clinical information updated (patient note, current meds, problems, and care plan are updated).


  • Optionally, billing codes are pulled in or selected and sent electronically.
  • Conditionally, if the patient has a change in their status, then their physician is alerted.
  • Care Hotline routes calls to staff scheduled to answer calls and will take a message if no one is available.

[1] CDC State of Aging and Health in America 2013