How To Leverage CCM To Thrive in Value-Based Care

With the Centers for Medicaid and Medicare Services (CMS) moving increasingly to a mandated value-based care (VBC) model, it will be vital for healthcare systems to increase their participation in programs that prioritize patient care and cost-efficiencies, while pivoting away from more traditional fee-for-service care models. 

Providers and health systems also are recognizing that the transition to VBC will be a fundamental and permanent shift in how care is delivered, measured, and billed. They will have to deliver effective care to patients, reduce the total cost of care, while keeping patients out of hospitals and emergency departments. Smart healthcare systems are realizing that adopting a chronic care management (CCM) program will play a key role in meeting quality and performance care goals in the new VBC vista. 

Using a CCM Program to Improve Patient Outcomes

Chronic Care Management programs reimburse providers through Medicare for providing and coordinating care with patients with two or more chronic conditions between regular office visits. CCM programs aim to improve patient care and satisfaction, while lowering costs and keeping people out of the hospital or emergency department.  

To achieve lowering healthcare costs, while improving patient care, is challenging for many healthcare systems today. To meet VBC mandates effectively, providers must ensure that patients fully understand their chronic conditions, because many don’t. Then providers need to engage longitudinally with their patients between office visits. This ongoing and consistent relationship will build trust and allow patients to keep their providers apprised of any new or worsening symptoms to their chronic condition(s)—or changes in their medication needs or home environment—that might affect their health. 

By staying in contact, providers can meet patients where they are and readily intervene before the patient ends up in the hospital or emergency room. But the strength of this relationship doesn’t happen by accident. Forming a relationship based on trust and communication takes time and commitment. If trust doesn’t exist, or communication breaks down, treatment may suffer. Conversely, when trust and communication are solidified, patient care, trust, and satisfaction all increase. 

This trusted relationship between patients and providers is at the foundation of healthcare and a CCM program can very effectively help to both extend and build the relationship between patients and their providers, helping patients to feel a genuine connection to their physician and care team. These patients are more likely to discuss their health issues, and this communication can enable early intervention, prevent hospitalizations, and prevent emergency department visits, which are all great examples of how a CCM program can help facilitate the kinds of conversations that are at the heart of value-based care. 

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A quality CCM program also places personalized care treatment plans and care coordination at the center of patient treatment. Care plans and treatment are tailored to an individual patient’s needs, which can make the treatment more effective and increase the patient’s satisfaction and adherence to the care plan. This contributes to better engagement and retention by the patient and reduced costs for the health system, as escalating health issues are addressed early and often. 

Supporting Quality Metrics

Quality performance metrics provide a specific purpose within the VBC model. While lowering the total cost of care is the goal, achieving high quality care delivery is just as important. If health systems are to achieve a balance of cost reductions and savings within a high quality of care landscape, the measurement of performance will need to be an important piece of the treatment process. A CCM program should be set up to leverage data-driven analytics that can support health systems in establishing metrics to meet their VBC quality performance goals. Examples of this might include scheduling annual wellness visits, tracking outcomes-based quality measures, or facilitating compliance with process-based quality measures like mammogram or colonoscopy screenings. 

By closely tracking these measurements, clinical interventions and outcomes can be monitored and improved. While the data alone won’t drive care management, it can provide critical insights that guide treatment decision-making and clinical interventions. A CCM program will use this data to track patient progress, identify trends and patterns in treatment, and allow the care team to coordinate earlier (primary care) interventions.

Lowered Costs and Revenue Sharing

Many health systems grapple with making the strategic changes needed to align their care delivery system more closely with VBC payment models. Since CMS is expected to continue to push for value-based care, and since financial dynamics vary differently from those of traditional 

fee-for-service care models, health systems will need to address and adjust how they deliver some care in the future. An outsourced CCM program can be a cost-effective way to make some of these changes, while achieving VBC success. 

An outsourced CCM program also extends a health system’s clinical and financial resources in ways that may be challenging for in-house programs to achieve. For instance, an outsourced- CCM program can eliminate additional technology spends, while maximizing clinical efficiencies. Outsourced CCM programs bring their own technology and infrastructure, thereby eliminating the need for health systems to invest in additional technological resources, integrations, etc. Health systems won’t face burdensome out-of-pocket IT costs. The programs also employ their own clinical staff, eliminating costs for recruitment, training and benefits for the nursing team that would be required to support the CCM program. 

Many CCM programs also operate on a revenue-sharing model, where costs are covered by a share of existing reimbursements, so health systems are guaranteed to have net revenue. And by engaging patients longitudinally, and uncovering early primary care level interventions, the nominal impact on benchmark for delivering CCM services can be offset by the savings of keeping patients out of the hospital and the emergency department. The CCM program partnership ensures that both the health system and CCM program provider benefit from improved patient care outcomes, reduced costs, and shared revenue. 

In essence, a CCM program can boost patient engagement, deliver better patient outcomes, and strengthen a health system’s financial performance. These are all factors necessary to achieve success in a value-based care environment. 

CCM and the Future of Value-Based Care

Everyone understands by now that value-based payment models are here to stay and will continue to increase. However, success in VBC and risk models can be much simpler when low cost, high impact longitudinal care management programs like CCM are implemented within an existing population health strategy. To understand the importance of this, look no further than the 2025 Proposed Final Rule from CMS, where CMS references the importance of longitudinal care management more than a dozen times. 

Encouraging patients and providers to develop trusted relationships, streamlining care coordination and documentation, and reducing hospitalizations and emergency department visits will all help health systems achieve CMS’ value-based care goals of decreasing healthcare costs, while delivering high-quality care in an integrated and holistic manner. 

A well-run CCM program offers powerful tools in helping health systems drive performance, improve patient outcomes, capture better data analytics, navigate the complexities of the VBC landscape, and drive better financial performance for the organization. To make the partnership work effectively, CCM programs work to affect behavior change in patients, while clinical leadership can leverage the CCM program to affect behavior change in providers as well. 

As healthcare systems increasingly adopt value-based care mandates, a CCM program will likely become a significant piece in supporting the delivery of overall future care. 

If you would like to implement a CCM program, outsourcing is a viable and recommended path. 

Signallamp works as an extension of your providers, helping you to harness your physician- patient relationships to increase access to care, improve outcomes, and feed longitudinal patient engagement. We offer white glove, on demand, nursing capacity, dedicated only to your providers and patients and tailored to your workflows. Our unique remotely embedded nurse care model enables our nurses to become a truly integrated extension of your existing facility-base care team, all at no up-front cost to you. Our success is directly linked with your success. 

Ready to improve patient care with a Chronic Care Management Company? Learn how Signallamp Health can help you Take Care Further™ with remotely embedded Chronic Care Management. Schedule a consultation with us.