Connected Care Toolkit: Chronic Care Management Resources for healthcare Professionals and Communities

Patient Need Addressed: Care Coordination/Management, Chronic Conditions
Population Focus: Dual eligible
Demographic Group: Adult
Intervention Type: Service redesign
Type of Literature: Grey


Insights Results

Overview of resource

  • This toolkit includes information for healthcare professionals, professional and patient organizations, and community groups, including tips for getting started, fact sheets on the requirements for providing chronic care management (CCM) in practices, and educational materials to share with patients
  • The toolkit was designed to be used in 2 ways: 1) As a resource for healthcare 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


    • Patient benefits from CCM include provision of a care team who can help them plan for better health and stay on track for good health, reception of a comprehensive care plan, guidance of support needed between visits
    • Provider benefits from CCM include improved care coordination, patient compliance and connection, and practice growth
    • Many activities under CCM are billable and count toward the minimum monthly service time. These activities include providing CCM for patients outside of in-person visits (e.g., phone calls, emails), sharing patient’s health information with other healthcare professionals and providers, managing care transitions, and coordinating with home- and community-based services providers and documenting such activity in the patient’s medical record
    • The toolkit also includes ways to help healthcare decision-makers explain CCM services to other staff (e.g., billing requirements, education), and patients and caregivers (e.g., definition of CCM, prompting questions about CCM and typical services under such care)

    Key takeaways/implications

    • Medicaid Health Homes is an optional Medicaid state benefit that can help with CCM services