Patients may qualify for Chronic Care Management when they have two or more chronic conditions that are expected to last at least 12 months, or until the end of the patient’s life. These conditions should place the patient at meaningful risk of functional decline, acute exacerbation, decompensation, hospitalization, or death.
CCM does not have one fixed, closed list of qualifying diagnoses. Instead, eligibility is based on the patient’s documented chronic conditions, the expected duration of those conditions, and the clinical risk they create. Common examples include hypertension, diabetes, heart disease, COPD, asthma, chronic kidney disease, obesity, depression, anxiety, arthritis, dementia, Parkinson’s disease, cancer-related complications, chronic pain, and other long-term conditions that require ongoing care coordination.
Practical Ways to Identify Patients
Practices can often identify potential CCM candidates by reviewing patients who have:
- Two or more active chronic diagnoses
- Multiple maintenance medications
- Recent ER visits, hospitalizations, or readmissions
- Care needs involving multiple specialists
- Functional decline or high-risk comorbidities
Core Value Proposition
CCM is designed for patients managing two or more chronic conditions that are expected to last at least 12 months and create ongoing clinical risk. Health Nexus helps practices identify eligible patients, document program requirements, and provide ongoing care coordination between visits. This allows providers to support complex patients more proactively while creating a structured monthly reimbursable care program.
