Case Study: How Chronic Care Management Reduces ER Visits and Improves Outcomes

Story by Connor Danielowski / September 2, 2025

Emergency room visits are costly, disruptive, and often preventable. For one Southeast U.S. primary care clinic, partnering with Chronic Care Staffing to implement a Chronic Care Management (CCM) program led to:

• 60% reduction in ER visits within 6 months
  
• Lower readmission rates among high-risk patients
  
• Increased patient satisfaction and engagement
  
• New recurring Medicare reimbursements — without hiring additional staff
  

What Is Chronic Care Management (CCM)?

CCM is a Medicare-supported program that reimburses providers for delivering monthly, non-face-to-face care to patients with two or more chronic conditions.

Through CPT codes 99490 and 99439, practices receive payment for services such as:

• Medication reviews
  
• Appointment scheduling
  
• Care plan reinforcement
  
• Monthly phone check-ins
  

The Problem

The clinic faced high ER utilization among patients with:

• Congestive heart failure
  
• Type 2 diabetes
  
• COPD
  
• Hypertension
  

Staff were overwhelmed managing scheduling and refills, leaving little time for proactive outreach. Preventable ER visits and readmissions continued to rise.

The Solution: Partnering With Chronic Care Staffing

The clinic implemented CCM with Chronic Care Staffing’s outsourced care coordination model:

• Dedicated care coordinators assigned to each eligible patient
  
• Monthly phone calls to assess symptoms, medications, and barriers to care
  
• EMR-integrated documentation for seamless compliance and billing
  
• Real-time escalation alerts for patients at risk of readmission
  

No additional software. No new hires. Just consistent, CMS-compliant care delivered virtually.

Results After 6 Months

60% Decrease in ER Visits
Patients enrolled in CCM had fewer emergencies thanks to early intervention.

Higher Patient Satisfaction
Patients reported feeling more supported and confident managing conditions at home.

Lower Readmission Rates
Medication adherence checks and proactive monitoring prevented costly readmissions.

New Medicare Revenue
Reimbursements through CPT 99490/99439 created a reliable, recurring revenue stream.

Why CCM Works to Reduce ER Visits

• Early Detection: Monthly check-ins catch warning signs before they escalate.
  
• Medication Adherence: Coordinators reinforce prescription compliance.
  
• Care Plan Support: Patients stay on track with lifestyle and treatment goals.
  
• Patient Trust: Consistent communication builds stronger provider-patient engagements.
  

How to Start a CCM Program Without Adding Staff

With Chronic Care Staffing, practices can:

• Chart directly in the EMR in real time
  
• Ensure Medicare documentation is accurate and audit-ready
  
• Scale CCM enrollment quickly without increasing overhead
  
• Expand value-based care programs confidently
  

Final Takeaway

Chronic Care Management works. This case study demonstrates that proactive, virtual care coordination can reduce ER visits by 60%, lower readmissions, and boost patient satisfaction — all while strengthening a clinic’s financial sustainability.

At Chronic Care Staffing, we make CCM turnkey, scalable, and compliant.

Learn more about CCM with Chronic Care Staffing

Connor Danielowski

Chief Operating Officer, Chronic Care Staffing

Connor Danielowski is the Chief Operating Officer at Chronic Care Staffing, where he leads operations, strategy, and growth initiatives focused on delivering high-impact virtual care solutions. He brings a unique blend of clinical service knowledge and financial expertise to help healthcare organizations implement and scale Chronic Care Management (CCM), Remote Patient Monitoring (RPM), and other virtual care management services.

Connor began his career in investment banking and private equity, where he focused on investing in healthcare businesses and working closely with management teams to drive revenue growth and profitability. This experience shaped his hands-on, results-oriented approach to healthcare operations today.

He holds a degree in Accounting from Washington & Lee University and brings both analytical rigor and a patient-first mindset to his role. In addition to his work at Chronic Care Staffing, Connor serves on the development board for the MUSC College of Nursing. He lives in Charleston, SC, with his wife and son.

Categories: Chronic Care Management News