Why Chronic Care Management (CCM) Is a Must-Have for Value-Based Care Success

Value-based care (VBC) is no longer a trend—it’s the future of healthcare. As the Centers for Medicare & Medicaid Services (CMS) continues to push forward with value-based payment models, healthcare organizations are under growing pressure to deliver better outcomes while controlling costs.

Chronic Care Management (CCM) has emerged as a key strategy to thrive under both at-risk and capitated VBC contracts. Whether you’re in an ACO, participating in the Medicare Shared Savings Program (MSSP), or exploring capitation, CCM can help align your operations with the incentives of value-based care.

In this blog, we explore how CCM strengthens value-based care models, improves patient outcomes, and drives long-term clinical and financial success.

Understanding the VBC Landscape

At-Risk Contracts

In at-risk arrangements, providers remain fee-for-service but are accountable for cost and quality benchmarks. Shared savings—or shared losses—depend on hitting these metrics. This is common in ACOs and MSSPs operating under two-sided risk.

Capitated Contracts

Providers receive a fixed per-member-per-month (PMPM) rate to deliver care. Financial success depends on efficiency and prevention—since providers assume full responsibility for the cost of care.

Regardless of the model, reducing hospitalizations, ED visits, and care gaps is critical—and this is where CCM shines.

Why Value-Based Care Needs CCM Now

CMS has made it clear: the era of value-based reimbursement is here. Over 50% of Medicare beneficiaries are now tied to value-based models, and that number is only growing. To succeed, healthcare organizations must shift their focus to proactive, coordinated care—and that starts with infrastructure.

Chronic care management fills the operational and relational gaps that traditional claims data and predictive models can’t reach.

CCM in Action: Blocking and Tackling for Better Outcomes

What Does It Look Like in Practice?

Veteran CCM strategist Jeremy Floyd puts it simply: success comes down to “basic blocking and tackling.” This includes:

• Quarterly chronic care visits
• Annual wellness visits
• Medication reconciliation
• Preventive screenings
• Addressing social determinants of health (SDOH)

CCM provides high-impact, low-cost patient touchpoints between office visits that support these efforts—and it works.

Real Outcomes from Real Interventions

Here’s how CCM improves outcomes in value-based care:

Medication Adherence

Nurses conducting med recs uncover side effects, affordability issues, and dosing confusion. This alone can reduce hospitalizations by 10–20%.

Early Intervention

Subtle signs of infection or decompensation—like leg swelling—caught on a CCM call can lead to early treatment and prevent ER visits.

Closing Gaps

CCM helps schedule preventive screenings, follow-ups, and specialist care—directly improving quality scores and reimbursement.

SDOH Support

CCM nurses help patients overcome barriers to care, such as transportation, food insecurity, and emotional wellbeing—critical data points that claims data miss entirely.

Why Claims Data Isn’t Enough

Many organizations rely on retrospective claims data to guide CCM enrollment. But that data is often 60–90 days old and blind to present-day risk factors like:

• A change in caregiver support
• Depression or isolation
• Financial challenges
• Mobility or lifestyle changes

CCM uncovers what dashboards can’t—with live, compassionate conversations that capture what’s really going on.

The Enrollment Mistake That Costs ACOs

One of the most common pitfalls? Only enrolling the top 5% of “highest-risk” patients. It seems logical, but it fails to account for:

• Patient risk constantly shifting
• Claims data delays
• The many high-need patients who aren’t on the radar yet

A better strategy? Use data plus clinical intuition. CCM should reach beyond the obvious to provide preventive support before issues escalate.

How CCM Improves Quality and Coordination

Under models like MSSP, shared savings rely heavily on performance across quality measures. CCM helps close these gaps through:

• Preventive screenings (e.g., mammograms, colonoscopies)
• Depression, fall-risk, and ADL assessments
• Accurate coding through better documentation
• In-network referrals that keep care coordinated and cost-effective

This isn’t about box-checking—it’s about delivering real value to patients and payers alike.

CCM in Capitated vs. At-Risk Models

For At-Risk Contracts:

• CCM billing remains possible.
• Cost savings through reduced utilization outweigh program costs.
• Don’t limit enrollment to a narrow risk pool—broaden impact.

For Capitated Models:

• Every dollar counts—CCM spreads resources efficiently.
• Supports longitudinal care and patient engagement.
• Enhances predictability in outcomes and operations.

CCM aligns seamlessly with CMS’s vision of advanced primary care tied to prospective payments and quality-linked performance.

Final Thoughts: CCM Isn’t a Luxury—It’s a VBC Lifeline

In a healthcare environment defined by complexity, risk, and performance-based incentives, Chronic Care Management isn’t just helpful—it’s essential.

By empowering care teams to deliver proactive, patient-centered support, CCM improves outcomes, reduces costs, and builds trust with patients. It’s one of the few interventions that delivers clear wins for patients, providers, and payers alike.

Ready to strengthen your VBC strategy with high-performing CCM?
Book a call with our team today to explore how Tellihealth can help you design, launch, and scale your chronic care program.