Developed by CMS, the Connected Care Toolkit equips health care providers with resources to raise awareness about the importance of chronic care management (CCM) services for Medicare and dual-eligible patients managing multiple chronic conditions.
CCM is a critical component of primary care that contributes to better outcomes and higher satisfaction for patients. CCM codes can be billed for services furnished to patients with two or more chronic conditions who are at significant risk of death, acute exacerbation or decompensation, or functional decline. Two thirds of Medicare beneficiaries have two or more chronic conditions, which means many individuals can benefit from CCM services, including the help provided between visits. CCM can help deliver coordinated care to patients that will improve their health, increase satisfaction with their care and make care more person-centered.
This toolkit includes information for health care professionals, professional and patient organizations and community groups, including tips for getting started, fact sheets on the requirements for providing CCM in practices, and educational materials to share with patients.
This toolkit is designed to be used: 1) as a resource for health care professionals to successfully build out CCM services in their practices and 2) as a tool to educate colleagues, members of professional societies, patients and advocates about the importance of CCM in improving patient health and satisfaction
By offering these services, health care professionals can deliver the coordinated care their patients need and help patients stay on track by getting support between visits.