1. Risk Assessment Factor (RAF) score.

2. Hospital utilization.

3. Preventing Readmissions via better care transitions

4. Active management of high need/high cost patients

5. Manage/reduce post acute care spending

6. Increase referrals to ACO based providers/reducing leakage

7. Integrate behavioral health care into primary care settings

8. Medicare Shared Savings Program (MSSP)

9. Social Determinants of Health (SDoH)

Chronic Care
Management Benefits
Outsourcing Chronic
Care Management
Patient Care
Generate Greater
Practice Revenue
Patient Monitoring
Highly Qualified
Care Coordinators
What is Chronic
Care Management?
Who is Eligible for Chronic
Care Management?