- February 25, 2026
Disclaimer: This article is for educational purposes only and does not replace professional medical advice. If you or someone you love is experiencing a mental health emergency, call 988 (Crisis Lifeline) or 911 immediately.
If you’re living with more than one chronic condition like diabetes alongside hypertension, COPD alongside heart disease, depression alongside kidney disease, you already know that managing your health requires more than a few office visits per year. It requires coordination, consistency, and a care team that is actively engaged in your well-being between appointments.
That’s exactly what Chronic Care Management, or CCM, is designed to provide. It’s a structured, Medicare-supported program that extends your primary care team’s reach beyond the exam room.
It offers regular touchpoints, a personalized care plan, and proactive monitoring designed to keep you stable, informed, and supported year-round.
This article explains what CCM is, how it works, who qualifies, and how Windermere Medical Group uses it to deliver a higher standard of long-term care for our patients.
What Is Chronic Care Management (CCM)?
Chronic Care Management (CCM) is a structured healthcare service designed for patients living with two or more chronic conditions that require ongoing monitoring and coordination. CCM includes regular follow-ups, medication management, care planning, and communication between visits to help prevent complications and hospitalizations.
Established by the Centers for Medicare & Medicaid Services (CMS), CCM acknowledges a fundamental truth: managing complex, long-term health needs requires consistent engagement, not just periodic appointments.
CCM goes beyond the traditional office consultation model. It’s a coordinated program in which your care team actively manages your health between visits. The team will update your care plan, reconcile medications, coordinate with specialists, and check in on your progress monthly. CCM typically includes:
- Personalized care plans
- Medication monitoring
- Coordination between providers
- Follow-up communication between visits
- Preventive care planning
According to CMS, patients enrolled in CCM programs experience fewer hospitalizations, lower emergency department utilization, and measurably better chronic disease outcomes than those receiving standard care alone.
What Does a CCM Program Include?
A qualifying CCM program provides a comprehensive set of services designed to keep patients connected to their care team and on track with their health goals. A CCM program includes:
| CCM Service | What It Means for You |
| Comprehensive Written Care Plan | A personalized document outlining your diagnoses, medications, goals, and care team contacts |
| Monthly Care Coordination (20+ min) | At least 20 minutes of non-face-to-face care management every calendar month |
| 24/7 Access for Urgent Needs | Around-the-clock access to a care team member for urgent chronic care questions |
| Medication Reconciliation | Regular review to ensure your medications are accurate, safe, and working as intended |
| Specialist Coordination | Active communication between your primary care provider and any specialists involved in your care |
| Care Transitions Support | Follow-up and coordination when you’re discharged from a hospital or other facility |
| Health Goal Tracking | Monitoring progress on measurable targets like A1C, blood pressure, or weight |
Personalized Care Plans: The Foundation of CCM
A personalized care plan is one of the most important components of CCM. This plan outlines your diagnoses, medications, treatment goals, and preventive recommendations.
What a Personalized CCM Care Plan Includes
- Active diagnoses: Every chronic condition being managed, with clear documentation of its current status and treatment approach.
- Treatment goals: Specific, measurable targets for each condition, such as a target A1C range for diabetes, a blood pressure goal for hypertension, or a weight management milestone.
- Full medication list: Every prescription, over-the-counter medication, and supplement, with dosing, frequency, and the condition each addresses, is reviewed for accuracy and interactions.
- Care team directory: Contact information for every provider involved in your care, with each provider’s role clearly defined, ensuring seamless communication.
- Self-management instructions: What you should monitor at home, what readings or symptoms should prompt a call to your care team, and what to do in an urgent situation.
- Emergency and after-hours protocol: Specific guidance on how to reach your care team outside office hours and when to go to the emergency room rather than calling the practice directly.
Trusted Medical Care, Wherever You Are
With established offices in:
Who Qualifies for CCM?
- You have two or more chronic conditions that are expected to last at least 12 months or until the end of life
- Your conditions place you at significant risk of death, acute exacerbation, functional decline, or deterioration
- You are enrolled in Medicare Part B
- You are not currently enrolled in another care management program that would be duplicative
Common Qualifying Chronic Conditions
While many conditions can qualify, some of the most common include:
- Type 2 Diabetes
- Hypertension (High Blood Pressure)
- Heart disease / congestive heart failure
- Chronic obstructive pulmonary disease (COPD)
- Chronic kidney disease
- Depression or anxiety disorders
- Alzheimer’s disease and other Dementias
- Arthritis (Osteoarthritis or Rheumatoid Arthritis)
- Asthma
- Obesity
How Chronic Care Management Works?
The program operates through a structured monthly care coordination cycle that keeps patients actively connected to their care team between office visits. Here’s how the CCM process works, from enrollment through ongoing care:
- Eligibility review and enrollment consent: Your provider reviews your conditions against Medicare’s CCM criteria and walks you through what the program includes. Enrollment requires your consent and can be initiated at any regular office visit.
- Comprehensive health assessment: At enrollment, your care team conducts a full review of your current health status, active diagnoses, medications, specialist relationships, and social factors that may affect your care, such as transportation, living situation, or caregiver support.
- Personalized care plan creation: Using the assessment findings, your care coordinator and physician build a written care plan specific to your conditions, goals, and circumstances.
- Monthly care coordination touchpoints: Each calendar month, a member of your care team reaches out to check in on your health, review any changes, address medication concerns, follow up on specialist visits, and update your care plan as needed.
- Ongoing monitoring and early intervention: Between monthly touchpoints, your care team monitors incoming data, lab results, remote monitoring readings, prescription activity, and reaches out proactively when something signals a concern, rather than waiting for the next scheduled contact.
Care transitions support: When you’re discharged from a hospital, emergency room, or skilled nursing facility, your CCM team coordinates your transition back to ambulatory care, reconciles any medication changes, follows up on discharge instructions, and schedules prompt follow-up appointments.
CCM vs. Standard Primary Care: What's the Difference?
Patients sometimes wonder how CCM differs from the care they already receive through regular office visits. The distinction is meaningful:
| Feature | Standard Primary Care | With CCM Enrollment |
| Care Plan | Updated at office visits | Comprehensive written plan maintained continuously |
| Monthly Contact | As needed / patient-initiated | Proactive care team outreach every calendar month |
| After-Hours Access | On-call for emergencies | 24/7 access specifically for chronic care needs |
| Medication Oversight | Reviewed at appointments | Ongoing reconciliation between visits |
| Specialist Coordination | Via referrals | Active, documented communication between all providers |
| Care Transitions | Follow-up scheduled at discharge | Proactive, coordinated follow-up built into the program |
CCM is a layer-structured, proactive support on top of it. For patients managing two or more chronic conditions, that additional structure often makes a significant difference in outcomes, stability, and quality of life.
Conclusion
Chronic Care Management bridges the gap and offers a meaningful commitment to consistent, coordinated, patient-centered care. It offers a structured path to better outcomes, fewer crises, and a care team that stays engaged 365 days a year
For individuals living with multiple or high-risk conditions, structured monthly oversight, medication management, and seamless communication with their care team can significantly enhance outcomes and quality of life. Rather than reacting to flare-ups or emergencies, CCM focuses on prevention, organization, and long-term health planning.
At Windermere Medical Group, CCM is one of the ways we deliver on our promise to be a true long-term partner in health, not just a provider you see twice a year, but a team that actively supports you between every visit.
Ready to Get the Care You Deserve?
At Windermere Medical Group, our team is ready to partner with you for the long term. Schedule your CCM consultation at windermeremedical.com
FAQs:
1. Can I enroll in CCM if I only have one chronic condition?
No. CCM requires at least two qualifying chronic conditions expected to last 12 months or longer under Medicare guidelines.
2. Do I need a referral to enroll in a CCM program?
No referral is needed. Ask your Windermere Medical Group provider directly about CCM eligibility at your next appointment.
3. Can I opt out of CCM if I change my mind?
Yes. CCM enrollment is voluntary, and you can disenroll at any time without affecting the rest of your care.
4. Will CCM replace my regular office visits?
No. CCM supplements your in-person visits with monthly care coordination touchpoints; it does not replace scheduled appointments.
About the Author
Priya Bayyapureddy
Dr. Priya Bayyapureddy, MD is a board certified Internal Medicine doctor with over 20 years of experience in primary care Internal Medicine. Dr. Bayyapureddy completed her Internal Medicine residency at Emory University School of Medicine and internship at University of Tennessee College of Medicine at Chattanooga.
