Chronic Care Management, Inc. announced today that is has released clinical outcomes on its managed population for the first half of 2018.

Dr. William Mills, President and CEO of Chronic Care Management, Inc. said, “We are pleased to be the first chronic care management patient and practice support organization to publicly release clinical and utilization outcomes for our managed population. Reporting of outcomes drives transparency and illustrates the value of evidence-based attention to ‘in-between visit care.’” A video presentation overview of the company’s outcomes presented by Dr. Mills on the company’s website.

The company reported that between January and June of 2018, CCM Inc. managed over 21,000 patients in its full-service, clinically-integrated model, in addition to supporting the management of thousands of additional patients in practice-staffed care management models. The company supported low hospitalization and readmission rates by leveraging evidence-based outcome assessment tools to provide high-impact, low-cost touchpoints to patients with chronic medical and behavioral conditions. Dr. Mills said, “The key to our approach is that we focus entirely on using medical science and evidence-based workflow to drive the identification of clinical risks. We then link patients with identified risks to community resources such as home health, physical therapy, caregivers and other resources in close collaboration with the patient’s medical provider. This approach has helped us identify patients at high risk of falls, adverse drug interactions, 12-month mortality and many other important areas – which then enable us to help patients’ providers deploy resources to address such risks.”

CCM is a program launched by the Centers for Medicare and Medicaid Services (CMS) in 2015 to help  provide support for patients with multiple chronic conditions in-between their provider visits and episodes of care. The CCM program created a new Medicare-benefit to support beneficiaries with two or more chronic conditions by providing new “in-between visit” revenue to participating providers, stimulating practices to enhance their focus on goal-directed, person-centered care planning, and to provide “aging-in-place” resources such as proactive care management.

The CCM program is associated with positive clinical outcomes for patients – a recent study of the Medicare program showed that it is lowering hospitalization rates, emergency department use and skilled nursing days, while increasing engagement between patients and their practitioners. The program works by creating increased connectivity between patients with chronic conditions and their healthcare providers and matching patients with community-based resources such as home healthcare when appropriate.

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