1. Beth Chalick-Kaplan, DNP, CRNP, FNP-BC
August 2nd, 2017

2. What Is Chronic Care Management (CCM)? (continued)
Chronic Care Management (CCM) services by a physician or non-physician practitioner (Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist and/or Certified Nurse Midwife) and their clinical staff, per calendar month, for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until death, and that place the patient at significant risk of death, acute exacerbation / decompensation, or functional decline
Chronic care management is defined as services provided by a physician or non-physician practitioner and their clinical staff, per calendar month, for patients with multiple chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
CMS considers CCM as a critical component of primary care that contributes to better health and care for individuals.
CCM is person-centered and requires more centralized management of patient needs and coordination among practitioners and providers.
Timed services – threshold amount of clinical staff time performing qualifying activities is require per month
CCM is a critical component of care that contributes to better health and care for individuals
CCM offers more centralized management of patient needs and extensive care coordination among practitioners and providers

3. What Is Chronic Care Management (CCM)?
Ongoing CMS effort to pay more accurately for CCM in “traditional” Medicare by identifying gaps in Medicare Part B coding and payment (especially the Medicare Physician Fee Schedule or PFS)
Initially adopted CPT code beginning January 1, 2015 to separately identify and value clinical staff time and other resources used in providing CCM
Beginning January 1, 2017, CMS adopted 3 additional billing codes (G0506, CPT 99487, CPT 99489)
Detailed guidance on CCM and related care management services for physicians available on the PFS web page at:
In 2015 Medicare began paying separately under the Medicare Physician Fee Schedule for CCM services furnished to Medicare patients living with multiple chronic conditions.
CMS first established payment for CPT code 99490, to pay providers for at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
Patients will receive a comprehensive care plan and 20 minutes a month or more of their dedicated medical provider’s time for phone check-ins, and the ability to reach someone from their care team when they need to.
In 2017 three additional billing codes were adopted to provide reimbursement for increasing complex coordination and management services.
To find more information about CCM-related care and related care management services for physicians, visit the CMS Care Management page listed above.

4. CCM Cost Sharing
Currently CMS lacks authority under the law to remove the usual Part B cost sharing that applies to CCM services.
However, Medigap plans must provide wrap-around coverage of cost sharing for CCM, and most beneficiaries have Medigap or other supplemental insurance.
The majority of dually eligible beneficiaries (Qualified Medicare Beneficiaries) are exempt from cost sharing.

5. Connected Care
The Chronic Care Management Resource
The CMS Office of Minority Health (CMS OMH) is partnering with Federal Office of Rural Health Policy (FORHP) at the Health Resources and Services Administration (HRSA) under legislation to design and implement an education and outreach campaign to:
Inform professionals and consumers of the benefits of chronic care management services for individuals with chronic care needs, and
Focus on encouraging participation by underserved rural populations and racial and ethnic minority populations.
Connected Care was developed by the Centers for Medicare & Medicaid Services (CMS) Office of Minority Health (CMS OMH) in partnership with the Federal Office of Rural Health Policy (FORHP) at the Health Resources & Services Administration (HRSA).
It is a national public education campaign that seeks to raise awareness of the benefits of chronic care management (CCM) services among health care professionals and patients, including in rural areas and among racial and ethnic minority populations.

6. Campaign Audience Primary Audiences Secondary Audience
Drive awareness of the benefits of CCM
Provide tools to EPs, patients, and caregivers
Encourage the participation and adoption of CCM
Awareness
Tools
Adoption
Primary Audiences
Eligible practitioners (EPs) and Suppliers:
Eligible practitioners: Physicians, Clinical Nurse Specialists, Nurse Practitioners, and Physician Assistants
Eligible suppliers: Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
Consumers/Patients: Medicare and dual-eligible beneficiaries (Medicare & Medicaid) with two or more chronic conditions, with a focus on underserved rural populations and racial and ethnic minority populations
Secondary Audience
Caregivers of patients
The Connected Care campaign has two primary audiences. The first audience segment is health care professionals, which includes physicians, clinical nurse specialists, nurse practitioners, certified nurse midwives, and physician assistants. We are also looking to reach Medicare and dual-eligible beneficiaries with two or more chronic health conditions.
Through Connected Care, we will place a special focus on reaching underserved rural populations as well as racial and ethnic minorities.
Source:
Department of Health and Human Services, Centers for Medicare & Medicaid Services. Updated Chronic Care Management Fact Sheet.

7. Campaign Markets
Connected Care is a national public education campaign
CMS OMH and FORHP will target four states with more focused communications.
Using Medicare claims data, planners identified two markets—one rural county and one urban area—in four target states to implement more localized campaigns that include media promotion and community outreach
The Connected Care campaign is a national initiative with an in-depth targeted focus in four states for the first year. Using Medicare claims data, CMS identified two markets—one rural county and one urban area—in four states to implement localized campaigns with the support of CMS and HRSA Regional Offices.
Target markets were selected on a variety of factors, including Medicare-enrolled beneficiary data, existing use of chronic care management, prevalence of two or more chronic conditions among Medicare beneficiaries, adoption of Electronic Health Records, presence of racial and ethnic diversity including in rural areas, rural population and rural population density, geographic regional diversity, as well as the presence of Rural Health Clinics, Federally Qualified Health Centers, CMS Regional Offices, and HRSA Regional Offices.
Sources:
Prevalence of 2 or more chronic conditions: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. Chronic Disease Indicators (CDI) Data [online] URL:
Percent of primary care physicians that adopted certified EHRs: “Health IT Data Summaries.” Dashboard.health.gov N.p.,n.d. Web. technology-data-summaries.php?state=National&cat1=ehr+adoption#summary-data
Overall diversity: American Fact Finder Demographic Profile Data.
Percent rural population: United States Census Bureau Census Urban and Rural Classification and Urban Area Criteria.
Rural Diversity: The Housing Assistance Council. Race & Ethnicity in Rural America. (April 2012).
State
City (Urban)
County (Rural)
Georgia
Atlanta
Wilkinson County
New Mexico
Albuquerque
Colfax County
Pennsylvania
Philadelphia
Snyder County
Washington
Seattle
Clallam County

8. Campaign Pillars Partner-ships Regional Activation
National Education Webinars
Targeted Market Activities
In Clinic Outreach
Earned Media
Social Media
Paid Media
Radio PSAs
Campaign Pillars
The campaign includes a mix of outreach approaches, including paid and earned media; social media; partnership development; and patient and provider education. We have developed a comprehensive information hub on the CMS OMH website that provides links to a comprehensive set of materials about CCM for download.
As part of the education initiative, multiple resources are available at no charge to help health care professionals and their patients learn about CCM. These resources include:
A toolkit for health care professionals with detailed information about CCM, resources to help providers implement CCM, and patient education materials;
A partner toolkit that includes downloadable resources and suggested activities to get involved in the Connected Care campaign; and
Patient education resources, including a poster and postcard that can be used in the clinical or community setting.
All of our educational resources are available on the CMS website at
The website also includes links to the CMS resources, including the CCM Fact Sheet, billing and eligibility information, Frequently Asked Questions, and upcoming webinars.

9. Connected Care Resource Hub
Information for Health Care Professionals
Access resources and tools explaining the benefits of CCM and how to implement this service
Information for Patients
Access easy-to-read information on the benefits of CCM for Medicare beneficiaries living with two or more chronic conditions
Campaign Partnership Resources
Access information about partnering to bring awareness to CCM through the Connected Care campaign
Visit the Connected Care Hub at: go.cms.gov/CCM
First, we are very excited about the enhancements that we’ve made recently to our Connected Care website: go.cms.gov/ccm
Our goal is for this site to be a one-stop shop for chronic care management with all of our new products as well as links to chronic care management resources, including the existing CMS care management page with CM fact sheets and FAQs and information on Upcoming CCM Webinars and Events.

10. Patient Education Resources
Resources to help health care professionals educate patients about CCM services:
Overview of benefits of CCM for patients
Waiting room posters
Postcard to share with patients during visits
Animated video (Coming soon)
Links to prevention and disease education resources
To order materials, contact
We’ve created educational materials that can be adapted for physician practices and shared with patients.
We have in-clinic posters available to display in doctor’s offices, as well as postcards that can be shared with patients, all highlighting CCM benefits.
We are also finalizing an animated video for patients that explains the benefits of CCM (doctors can also play in their offices).
Again these materials are available to download at and if you are interested in ordering materials, you can us at

11. Partnerships
Partners are vital to the success of the Connected Care campaign
Professional societies, national advocacy groups, and local organizations stand at the frontline to support patients and health care professionals
Your support is critical to raising awareness about the benefits of CCM services
Partnerships are very important for this initiative. We encourage organizations such as those of you on today’s call that represent health care professionals, health systems, rural clinics and community health centers, patients, and organizations serving racial and ethnic minority populations, as well as caregivers to reach out to us and get involved at the national, state, and community levels.
To become a partner, us at:

12. Partner Toolkit
Use the Partner Toolkit to promote the benefits of CCM and share campaign resources with eligible health care professionals and patients
Suggested partner activities
Sample language for articles, blog posts, and s for outreach
Links to educational tools for health care professionals and patients
Links to shareable media and graphics
To download the toolkit, visit go.cms.gov/CCM
For our partners, we now have a partner toolkit available on our website. This toolkit is also web-based and available on our website to download as a PDF. It contains suggested activities for
The toolkit contains suggested activities that we hope will be useful for all types of groups who talk to health care professional and/or consumer audiences. It was designed to make your job a little easier to get information out about chronic care management. In the toolkit, we provide suggested ideas on how you can spread the word to include publishing a newsletter article or a blog post, or sending a blurb in a newsletter or listserv. We will also have social media resources such as sample facebook posts and tweets along with graphics coming soon. Each of these will be offered in both English and Spanish, so we can reach a wider network of consumers and partners.

13. Promote CCM and Connected Care Resources
Use the tools in the Partner Toolkit to promote chronic care management and campaign resources through multiple channels, such as: s
Listservs
Newsletters
Social media
Phone Calls
Webinars
Events
Meetings
Conferences
Promote CCM and Connected Care resources at community activities, conferences, or other events.
Here, again you can see some of the ways that you can share the resources and CCM information through your existing communication channels.
So, we hope that you will join us in making this initiative a success!

14. Regional CCM contacts

15. Regional CMS CCM Contacts
Headquarters, States
CCM Contact 1
Boston, MA, VT, NH, ME, RI, CT 2
New York, NY, NJ, RP, USVI 3
Philadelphia, PA, DE, WV, VA, DC, MD 4
Atlanta, GA, KY, TN,NC, SC, AL, MS, FL 5
Chicago, IL, MN, WI, MI, IN, OH 6
Dallas, TX, NM, OK,AR, LA 7
Kansas City, MO, NE, IA, KS 8
Denver, CO, MT, ND, WY, SD, UT 9
San Francisco, CA, NV, AZ, HI, GU, AS, MP 10
Seattle, WA, OR, ID, AK

16. Contact Us
Visit the Connected Care Resource Hub at:
For questions about the Connected Care campaign and its resources, contact,
For more information on the CCM Connected Care campaign, visit our website at go.cms.gov/ccm.
You can also us at for CCM questions or to order our new products.