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How To Leverage CCM To Thrive in Value-Based Care

Published: 7/26/2024Updated: 8/7/20257 Min Readauthor-drew-kearneDrew KearneChief Strategy Officer

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 traditional fee-for-service care models.

Providers and health systems are recognizing that the transition to VBC will be a fundamental and permanent shift in how care is delivered, measured, and billed. They must deliver effective care, reduce the total cost of care, and keep patients out of hospitals and emergency departments. Smart healthcare systems realize that adopting a chronic care management (CCM) program plays a critical role in meeting quality and performance goals in the new VBC environment.

Using a CCM Program to Improve Patient Outcomes

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

Reducing healthcare costs and improving patient care simultaneously is challenging for many healthcare systems. To effectively meet VBC mandates, providers must ensure patients fully understand their chronic conditions and remain engaged between office visits. This ongoing relationship builds trust, enabling patients to communicate any new or worsening symptoms, medication changes, or home environment factors affecting their health.

Consistent communication allows providers to intervene proactively, helping patients avoid hospital or emergency visits. Trust-based relationships require intentional, ongoing communication. When effectively established, patient care, trust, and satisfaction increase significantly.

A CCM program extends and reinforces the patient-provider relationship, fostering a genuine connection with the physician and care team. This enhanced relationship encourages open dialogue, enabling early intervention, preventing hospitalizations, and reducing emergency visits—all central to value-based care.

Quality CCM programs center on personalized care plans and care coordination tailored to each patient’s needs, enhancing treatment effectiveness, patient satisfaction, and adherence. Early intervention reduces costs for health systems as emerging health issues are addressed promptly.

Supporting Quality Metrics

Quality performance metrics are essential in the VBC model. While lowering care costs is crucial, delivering high-quality care is equally important. Achieving both cost reductions and quality care requires careful performance measurement.

CCM programs should leverage data analytics to help healthcare systems meet VBC quality performance goals. Examples include scheduling annual wellness visits, tracking outcomes-based quality measures, and facilitating compliance with process-based measures like mammograms or colonoscopy screenings.

Closely monitored metrics guide clinical interventions and improve outcomes. While data alone won't drive care, it provides insights crucial for decision-making and early interventions.

Lowered Costs and Financial Sustainability

Health systems often grapple with aligning care delivery with VBC payment models. CMS will continue emphasizing value-based care, necessitating adjustments from traditional fee-for-service models. Outsourcing CCM programs can be a cost-effective method to achieve these changes successfully.

An outsourced CCM program expands a health system’s clinical and financial resources beyond in-house capabilities. It eliminates extra technology expenditures and maximizes clinical efficiencies. CCM programs provide their technology and infrastructure, eliminating the need for additional investments and reducing IT costs.

Furthermore, outsourced CCM programs employ their own clinical staff, removing the financial burdens associated with recruitment, training, and employee benefits. This approach supports cost-effective operational scalability.

Many CCM programs use revenue-sharing models, covering costs through shared reimbursements, ensuring net revenue for health systems. Longitudinal patient engagement and early interventions reduce hospitalizations and emergency visits, offsetting nominal benchmark impacts from CCM services. CCM partnerships mutually benefit health systems and program providers by improving patient outcomes, reducing costs, and sharing revenue.

Effectively managed CCM programs boost patient engagement, deliver better outcomes, and enhance a health system’s financial performance—essential factors for success in value-based care.

CCM and the Future of Value-Based Care

Value-based payment models are firmly established and growing. Success in VBC and risk models becomes more straightforward when low-cost, high-impact longitudinal care management programs like CCM integrate within existing population health strategies. The 2025 CMS Proposed Final Rule highlights the importance of longitudinal care management numerous times.

Building trusted patient-provider relationships, streamlining care coordination, and reducing hospital and emergency visits align directly with CMS’ goals: decreasing healthcare costs while providing integrated, holistic, high-quality care.

A well-executed CCM program offers powerful tools to drive performance, improve patient outcomes, enhance data analytics, navigate VBC complexities, and optimize financial performance. CCM programs facilitate patient behavior changes, while clinical leadership can leverage these programs to influence provider behavior positively.

As healthcare increasingly adopts value-based care mandates, CCM programs will become pivotal in supporting comprehensive future care delivery.

Implementing a CCM Program with signalCCM, Powered by Tellihealth

If you want to implement a CCM program, outsourcing is an efficient and recommended approach.

signalCCM, powered by Tellihealth, integrates seamlessly with your providers, strengthening physician-patient relationships, increasing care access, improving outcomes, and boosting longitudinal patient engagement. We provide dedicated, on-demand nursing support tailored to your workflows, becoming a genuinely integrated extension of your existing care team—without upfront costs.

Our success aligns directly with your outcomes.

Ready to enhance patient care with a comprehensive Chronic Care Management solution? Discover how signalCCM, powered by Tellihealth, can help your organization excel. Schedule a consultation today.