The CMS Kidney Care Choices (KCC) Model, including Kidney Care First (KCF) and Comprehensive Kidney Care Contracting (CKCC), incentivizes nephrologists to deliver high-quality, patient-centered care while managing costs. When used together, Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) are crucial tools that help providers do just that - optimizing performance under value-based kidney care models.

1. Overview: KCC Model & Nephrology

• The KCC Model promotes coordinated care for patients with CKD stages 4–5 or ESRD, emphasizing value, preventing dialysis progression, and encouraging transplantation or home dialysis.
• Successful participation requires meeting quality measures, managing the total cost of care, and supporting patient engagement through structured programs.

2. CCM & RPM: Key Levers for Performance

Prevent Hospitalizations & Emergency Care

• RPM enables early intervention for fluid overload and hypertension, helping reduce emergency visits and admissions.
• CCM reinforces care coordination, patient education, medication adherence, and symptom management, ensuring patients stay on track with their post-acute and maintenance care plans. 

Improve Quality Metrics

CCM has been shown to drive measurable improvements in diet, fluid management, BP control, symptom tracking, transplant readiness, and care coordination metrics for kidney patients, supporting KCC scorecard requirements.

Reduce Total Cost of Care

By lowering hospitalization rates and preventing complications, CCM/RPM helps practices hit thresholds for shared savings or incentives under CKCC and KCF models. 

Boost Patient Engagement

Regular CCM touchpoints and interactive RPM data sharing foster stronger patient adherence and satisfaction, reinforcing quality outcomes. 

3. Real-World Benefits: Evidence in Action

Nephrology clinics using CCM + RPM have reported:

• Earlier detection of potential issues, allowing for interventions that help delay the progression of kidney disease
• Better management of comorbidities such as hypertension and diabetes
• Enhanced patient engagement and self-management
• Improved medication adherence
• Stronger patient continuity of care

Improvements in these areas have positively impacted KCC core care metrics, such as increased home dialysis starts and higher preemptive transplant rates. 

4. Actionable Tips for Nephrologists

• Identify eligible patients aligned with KCC (CKD stages 4/5 or ESRD).
• Obtain patient consent for CCM enrollment and set RPM protocols.
• Deploy cellular-enabled RPM devices to ease patient onboarding and ensure compliance.
• Schedule monthly CCM touchpoints and log separate clinical time.
• Monitor outcomes diligently (hospitalizations, BP control, engagement) to support performance reviews and shared savings.

Frequently Asked Questions (FAQ)

Q: What are the KCC model options?
A: The model includes KCF (for nephrology practices only) and CKCC options (Graduated, Professional, Global) for integrated care entities. 

Q: How do CCM and RPM align with value-based care goals?
A: Through enhanced care coordination and monitoring, CCM & RPM help reduce hospital admissions, improve quality scores, and support cost savings performance.

Q: Can CCM and RPM be applied together in KCC programs?
A: Yes, when documented separately and managed correctly, they operate in tandem to enhance care delivery and financial outcomes.