Chronic Care Management, Behavioral Health Integration and Annual Wellness Visits

Are the foundation of improving the ACOs quality metrics and outcome measures. Here are the areas that Chronic Care Staffing’s Care Management Services increase ACOs overall impact:


  1. Risk Assessment Factor (RAF) score. Looking at the ACO quality measures for the RAF scores CCM can help positively impact the following with what we have incorporated into our monthly calls:
  2. At risk population- Diabetes, Hypertension, CAD- patients with poor control and elevated HGA1C >8/>9 categories, LDL, BP, Tobacco cessation: We provide education on chronic condition control and self-management techniques, we look for compliance with medication regimens, appointment follow-ups, and laboratory follow-ups, etc. We remind patients that may not be completely compliant or maybe overdue to follow up with their providers and assist with making appointments.
  3. Hospital utilization starts with increasing the patient’s awareness and knowledge of their chronic conditions and how to better self-manage their diagnoses. This patient education will assist in decreasing hospital/ER utilizations. We also educate the patients to either call their care coordinator or their provider’s office with any change in condition in order to get them scheduled for a checkup to reduce the chances of being hospitalized. We have seen firsthand how our calls have impacted this by the ability to recognize acute changes and assist the patient in making an appointment with their provider.
  4. Preventing readmissions via better care transitions- Care transitions are when the patient is most at risk for recidivism. We have been able to identify patients that have been hospitalized even before the providers are aware. We perform medication reconciliations, discuss the reason for the hospitalization, provide education, and assist in post-hospital appointments with their provider. Additionally, we place these patients on an every 2-week follow-up call to check on their health status.
  5. Active management of high need/high-cost patients- With each monthly CCM call, we are performing in-depth chart reviews and holding conversations with the patients discussing their chronic conditions. Again, we are increasing their awareness and knowledge of their chronic conditions and offering education on how to better self-manage. We are reviewing labs, medications, referrals, office visits, and diagnostics with the goal of closing any gaps in care and keeping the patient and provider well informed.
  6. Manage and reduce post-acute care spending which is achievable with our experienced care coordinators managing transitions of care.
  7. Increase referrals to ACO-based providers/reducing leakage – This keeps patients attributed to the ACO under the same umbrella of care when they see specialists.
  8. Integrate behavioral health care into primary care settings- This is achievable by using the Behavioral Health Integration program so that patients with these diagnoses are more closely monitored.
  9. Medicare Shared Savings Program (MSSP)
  10. Social Determinants of Health (SDoH)
Chronic Care
Management Benefits
Outsourcing Chronic
Care Management
Patient Care
Generate Greater
Practice Revenue
Examples of
Chronic Conditions
Highly Qualified
Care Coordinators
What is Chronic
Care Management?
Who is Eligible for Chronic
Care Management?