Chronic Care Management and Remote Patient Monitoring: How Ongoing Care Works Between Visits
Most of the work of managing a long-term health condition happens between office visits: taking medications, checking blood pressure or blood sugar, noticing new symptoms and knowing who to call. Chronic Care Management (CCM) and Remote Patient Monitoring (RPM) are two services designed to support patients during that time. This guide from Advanced Health Associates explains what each service is, who may be eligible and what to ask your care team.
What is Chronic Care Management?
Chronic Care Management is a Medicare-recognized service for patients living with two or more chronic conditions that are expected to last at least 12 months and that put the patient at significant risk of decline or complications. Common examples include high blood pressure, heart failure, atrial fibrillation, diabetes, chronic kidney disease, COPD and arthritis.
Instead of a single appointment, CCM is a monthly service delivered largely by phone and secure communication. A clinical care team member, working under the direction of your physician or other qualified practitioner, typically:
- Creates and maintains a comprehensive care plan that lists your conditions, medications, goals and the specialists involved in your care.
- Reviews your medications and helps you understand how and when to take them.
- Checks in regularly to ask how you are doing and whether anything has changed.
- Helps coordinate care with specialists, labs, imaging centers, pharmacies and home health agencies.
- Helps you through transitions, such as returning home after a hospital stay.
- Gives you a way to reach the care team when you have questions.
What is Remote Patient Monitoring?
Remote Patient Monitoring uses connected medical devices to send health readings from your home to your care team. Depending on your conditions, a device might measure blood pressure and pulse, weight, blood oxygen or blood glucose. Readings are transmitted automatically, often through a cellular connection, so you do not need a smartphone or home internet for many devices.
The care team reviews the readings and contacts you when something needs attention, for example a run of high blood pressure readings or a rapid weight gain in a patient with heart failure. The goal is to spot trends early and adjust care before a small problem becomes a bigger one. RPM does not replace emergency care: if you have chest pain, severe shortness of breath, signs of a stroke or another emergency, call 911.
How CCM and RPM work together
The two services are separate, but they complement each other. RPM provides objective data from home; CCM provides the human relationship, care plan and coordination that turn that data into action. A patient with high blood pressure and heart failure, for example, might use a home blood pressure cuff and scale while a CCM nurse reviews medications, explains what the readings mean and coordinates with the cardiologist.
Because Advanced Health Associates brings cardiology and primary care together in one network, these services can help keep both doctors working from the same plan. Our earlier article explains how coordinated cardiology and primary care works.
Who may benefit
Your care team decides whether a service is appropriate based on your health and the program's requirements. Patients who often benefit include those who:
- Live with several chronic conditions and see more than one specialist.
- Take multiple medications or have had recent medication changes.
- Have blood pressure, weight or blood sugar that is hard to keep in range.
- Were recently discharged from a hospital or skilled nursing facility.
- Live alone, or far from the office, and want an easier way to stay in touch.
What to know before you enroll
Your consent is required
Medicare requires that you agree to receive CCM, and that you are told about the service, your right to stop at any time and any cost-sharing that may apply. Your consent is documented in your record. RPM also requires your agreement and an established relationship with the practice that orders it.
Costs depend on your coverage
Under Original Medicare, CCM and RPM are covered under Part B, and the usual Part B deductible and coinsurance may apply. Supplemental insurance may cover some or all of that cost-sharing, and Medicare Advantage plans set their own rules. Coverage varies, so ask the office and your plan what you would owe before you enroll.
One practice coordinates CCM
Medicare generally allows only one practitioner to bill for CCM for a patient in a given month. If you already receive CCM from another office, tell your care team so services are not duplicated.
Questions to ask your care team
- Which of my conditions would the care plan cover, and who will be my main contact?
- How often will someone check in with me, and how do I reach the team after hours?
- Which device would I use, who sets it up, and what happens to my readings?
- What readings should prompt me to call the office, and when should I call 911 instead?
- What will this cost me under my plan, and how do I stop if I change my mind?
Tips for getting the most out of monitoring
- Take readings at the same times each day, following the instructions you are given.
- For blood pressure, sit quietly for five minutes first, with your back supported, feet flat and arm resting at heart level.
- Weigh yourself in the morning after using the bathroom and before eating, if your plan includes weight checks.
- Keep a short list of symptoms, missed doses or unusual events to share with the care team.
- Bring your devices or a printout of recent readings to your office visits.
Common questions
Is CCM the same as a home health visit?
No. Chronic Care Management is mostly provided by phone and secure communication from your doctor's office. Home health care involves clinicians visiting your home and is ordered separately when you qualify.
How Advanced Health Associates can help
Chronic Care Management and Remote Monitoring are among the services offered across the Advanced Health Associates network, alongside cardiology, primary care and internal medicine. Practices that take part in value-based care may also work with Advanced Health ACO on care coordination. To ask whether CCM or RPM is right for you, request an appointment, visit our locations page or call 941-412-0026. Service availability varies by location, so please call to confirm.
This article is for general education and is not medical, legal or insurance advice. Medicare rules and coverage can change; check with your plan or Medicare.gov for current details. If you are having a medical emergency, call 911.