Affordable Solutions for Medical Practices
Affordable Solutions for Medical Practices
(866) 382-5932 Support Login

Improve Chronic Care Management with Remote Care

Notepad, Pen, Injection and Sugar measurement kit in table

“The cost of healthcare has soared to untenable heights. In the United States, federal healthcare spending is rapidly approaching 20% of GDP. Furthermore, chronic disease is highly prevalent, accounting for nearly 90% of all healthcare spending. Additionally, it costs 3.5 times more to treat chronic diseases than it does other conditions, and they account for 80% of all hospital admissions. In recent years, rapid advancements in healthcare delivery models and low-cost wireless communication have spurred optimism in finding cost-effective, value-enhancing solutions to these issues.”

~ American Heart Association

Improving chronic care management services is crucial to the success of the independent medical practice for many reasons. The first priority, of course, is to be able to provide the highest level of professional care to maintain and sustain patient health. In fact, The Centers for Medicare & Medicaid Services (CMS) is recognizing more and more that Chronic Care Management, or CCM, is a critical component of primary care. The COVID-19 pandemic focused a spotlight on the need for increased remote care capabilities, and CMS revised some of its reimbursement regulations in response.

Despite the revisions, however, chronic or long-term patients can still cause a severe drain on the physical and financial resources of the practice. Patients with chronic conditions must be managed closely, with regular monitoring of vital signs, and glucose levels, as well as heart and lung functions. Staff must input this data into the EHR, analyze it, and communicate with the patient if action needs to be taken. Consistent attention is required for long periods of time, months or even years, and all of it must be accurately coded and billed, so the practice can be compensated for its efforts. Chronic Care Management covers a wide range of patient circumstances, including:

  • Those with several conditions, or multiple prescriptions that need to be monitored for possible interactions and continuing efficacy.
  • Addictions.
  • Patients with long-term stroke, arthritis, or orthopedic recovery situations.
  • Cancer or infectious diseases.
  • Chronic health conditions such as diabetes, hypertension, or COPD that need continual check-ups.
  • Weight management and care.
  • Conditions that might require coordination with medical specialties and outside services.
  • Age-related, psychiatric or cognitive impairment situations which impact the ability to participate in activities of daily living.

What is Included in Chronic Care Management?

In addition to specifying health conditions, Chronic Care Management includes a number of reimbursable activities set out by CMS:

  • Care management of up to 20 minutes per month of clinical staff time is allowed, under the direction of the physician or other qualified healthcare professional.
  • Recording patient health information.
  • Development and maintenance of a comprehensive electronic care plan.
  • Managing transitions of care.
  • Coordinating and sharing patient health information under interoperability guidelines.
  • The practice must use a certified electronic health record (EHR), although faxing is allowed to share the care plan with the patient.

Remote Care Services to Improve Chronic Care Management

One question independent practices were forced to face during COVID was how to provide such high levels of chronic care management on a remote basis. Fortunately, ever-evolving technologies continue to make the process efficient and cost-effective:


Telehealth solutions increase the ability of your practice to remotely deliver in-home patient care. They allow you and your medical staff to quickly and easily initiate telehealth video and secure text conversations and maintain logs of those chats and videos for billing and audit purposes.

Virtual Preventative Care Assistant

Amazing Charts now offers the capability to add external remote care services to your patient care kit by adding remote staff, or contracting out existing staff, to reduce labor costs while maintaining patient continuity. In cases of CCM, the Virtual Preventative Care Assistant can augment staff in support of televisits.

Electronic Health Records (EHR)

Make the most of technology by using your EHR to support your Chronic Care Management Initiative. Components of a comprehensive EHR include easy charting capabilities, templates, e-Prescribing, scheduling, and a patient portal.

Remote Patient Monitoring (RPM)

Part of the telemedicine spectrum, RPM incorporates a variety of wired or wireless devices that help to capture patient data and transmit it to the medical caregiver for analysis. These might include wearable or implantable devices, blood pressure cuffs, glucose meters, biosensors or pulse oximeters. Other devices allow patients to transmit user-entered data or facilitate access to secure record storage. Abnormal readings should be flagged for review.

Getting Your Independent Practice Ready for a Chronic Care Management Initiative

Once you have the technology in place for a Chronic Care Management initiative, your independent medical practice will also need to take other components into consideration, including:


Patients must have a designated physician/NP as their clinician. 24/7 access is required to address urgent care needs. Decide who in your practice will be tasked to the CCM team and discuss scheduling concerns.


Both patients and team members need to be educated about the benefits of participating fully in the chronic care management program.


Obtain and maintain documented patient consent to participate in the process, being sure to adhere to all CMS, state, data security and HIPAA guidelines. Include full disclosure of how any technology will be used, liability and malpractice procedures, billing and insurance information, and details on data security measures and potential risks to patient privacy.


Your billing department may need to take a refresher on the latest CMS codes for CCM cases, or you may want to consider a Medical Billing Service that can handle the hassle of billing for you.

Guiding Principles of Remote Care

In the shift from practice-centric to patient-centric delivery models, remote care initiatives can help the independent practice provide increased access to care for the most at-risk populations. Because it involves changes for both staff and patients, guiding principles to keep in mind when implementing a chronic care management initiative at your independent practice should include:

  • All remote care services should reflect a patient-centered approach to providing medical care, while considering best practices for your medical specialty.
  • Plan, implement, evaluate and evolve your CCM program to maximize effectiveness for both patients and staff.
  • Address the needs of all patient cohorts without disenfranchising technically, challenged, financially disadvantaged, or limited mobility populations.
  • Customize your services to meet the needs of your practice and patients. Do not create an unnecessary burden on staff or patients.
  • Allow easy access to health information for patients and other medical providers. Provide training and support for patients and caregivers.
  • Immediately integrate all information into patient EHRs.
  • Use technologies from reputable vendors that have been proven in actual patient care scenarios.
  • Follow state and federal laws regarding the use of remote care services.
  • Always seek to promote quality of care, patient safety, and positive health outcomes.
  • Record, deliver, analyze and address accurate data to assist in the delivery of chronic care measures.
  • Establish practice standards to screen, select, and verify data communicated by the patient, family, or caregiver.
  • Establish internal protocols to address issues of who is eligible to utilize remote care services, how they are to be used, what actions may be taken, and when a patient must be seen in-person for more intensive care.
  • Strive to meet or exceed applicable state and federal legal requirements for medical information privacy, including compliance with the Health Insurance Portability and Accountability Act (HIPAA) as well as state privacy, confidentiality, and data security laws.
  • Educate patients and providers about what data points are collected and maintained through remote care, how they will be used, and what other users and entities will have legitimate access to this information.
  • Advise patients of any privacy control settings which enable them to determine who has access to data that is collected and stored about them.
  • Provide services as allowed, and accurately bill patients, insurance companies, and Medicare for time engaged in chronic care management.
  • Work with a vendor who understands your needs and have the experience to help efficiently implement your CCM initiative.

Case Study of Applying Remote Patient Monitoring

“Remote Monitoring a Valuable Tool for Reducing Heart Failure Readmissions And Hospitalizations”

~ Teresa Sieck, PhD, Physicians Practice, July 22, 2021

According to a recent article in Physicians Practice, heart failure accounts for some 11 million physician visits each year; however, new technologies enable more effective Remote Patient Monitoring and Chronic Care Management without requiring patients to even leave their home. This process became even more crucial during COVID, as evidenced by the updated remote patient monitoring reimbursement rules from CMS. In addition to helping independent practices continue to monitor patients during the pandemic, these new codes provide further financial incentives for care providers to adopt this new technology.

In the article Rachel Robinson, director of quality and risk management for MercyOne Iowa Heart Center, revealed that the Center had enrolled 450 patients in a remote monitoring study. Results showed improvement in lower readmission and hospitalizations, as well as increased use of directed care therapies for heart treatment.

Benefits of Using Remote Care Services to Improve Chronic Care Management

Remote care can empower patients to better manage their health by participating more fully in the health care process. Remote care services can provide the independent practice with a fuller view of a patient’s health over time, increase its visibility into a patient’s adherence to a treatment, and enable timely intervention before a costly care episode.

Clinicians and care providers can strengthen their relationships with, and improve the experience of, patients by using the data sent to them, and their conversations or messaging, to develop a personalized care plan and engage in joint decision-making to foster better outcomes.

CCM refocuses attention on providing services that lead to better population health. Along with improved care, it also provides many benefits to the independent medical practice:

Better Outcomes

Improved care coordination and increased patient involvement leads to better health outcomes.

Financial Incentives

Practices can receive CMS reimbursement for providing monthly CCM services per the stated guidelines.

Streamlined Office Efficiency

A systematic approach to Chronic Care Management enables the practice to operate at the highest levels of efficiency.

Higher Patient Engagement

Encouraging patients to use CCM services gives them the support and motivation they need to follow good health habits between office visits.

Increased Compliance

Appointment and test reminders, increased education and access to personal information gives patients a feeling they can do something positive in working with a medical care team to improve their health.

Improved Patient Satisfaction

Making CCM services available helps improve office efficiency, which leads to improved patient satisfaction and increased patient loyalty.

Improved Staff Satisfaction

A better-performing program that leads to positive outcomes for some of the most challenging cases can make staff members feel better about their jobs, leading to increased retention.

Reduced Emergency Care

Patients with higher control over chronic conditions can decrease emergency room visits and hospital stays, thereby reducing costs for insurance providers.

Assured Revenue Stream

CCM provides another method of sustaining and growing an independent practice without adding additional facilities or requiring an increase in necessary personnel. It provides additional resources and care for high-need patients, while allowing providers to continue providing care to the balance of their patient population.

Today’s patients expect a different kind of healthcare experience. Remote care makes it easier to follow-up with chronic care patients, and make sure everything is going well. Most importantly, taking advantage of the latest in remote care services will not only help your practice thrive, but remain independent in the times ahead.

Healthcare Technology Solutions Designed By and For Independent Practices

Amazing Charts was founded in 2001 by a practicing family physician to help medical practices thrive. We have grown consistently since then by creating easy-to-use solutions for delivering patient care. Today, we offer a variety of additional capabilities designed to help independent practices succeed, including Electronic Health Records, Practice Management, Billing Services, Population Health and Remote Care. Call 866-382-5932 to learn about our products, schedule a practice consultation, and learn more about telehealth pandemic lessons that can help your independent practice grow.

Subscribe To Our Newsletter

Great! Click on one of the products below to learn more.

Frustrated with expensive software that requires dozens of clicks to document a note? Try Amazing Charts instead! Rated #1 for usability in physician surveys.

Our affordable US-based revenue cycle management service takes the work of billing off your hands.

Our Practice Management solution lets you manage patient records, insurance, and billing to maximize staff efficiency.

Tools to aggregate, analyze, and achieve results, such as better patient care and decreased costs.

Let's get you to the right destination:

Additional solutions to help your independent practice:

Practice Management

Take control of your finances!

Amazing Charts Practice Management

Our Practice Management solution lets you manage patient records, insurance, and billing to maximize staff efficiency.

Learn More

Medical Billing / RCM

Let us handle billing for you!

Medical Billing / RCM

Our affordable US-based revenue cycle management service takes the work of billing off your hands.
Learn More

Population Health

Improve care across your patient population!

Population Health

Tools that can help improve both patient care and your practice's bottom line.
Learn More